Overview

Marco Island Urgent Care
Naples Community Hospital
NCH Bonita
NCH NE
NCOL


Sheet 1: Marco Island Urgent Care

Marco Island Urgent Care






































File Effective Date: 1/1/2021 - 12/31/2021






































Note: File Contains Services Provided by MIU














































































Facility Name Primary Code Shoppable Service Description Revenue Code Revenue Code Description Service Location Billed Charge Discounted Cash Price Minimum Negotiated Allowable Maximum Negotiated Allowable Aetna Aetna International Aetna MCR ADV Beech Street Blue Cross Health Options Blue Cross NWB Blue Cross PPC Blue Cross Traditional Cigna Consortium First Health Freedom Health HMO/PPO MCR ADV Freedom Health PPO Humana Choice Care Humana MCR ADV HMO/PPO Mail Handlers Molina MCD ADV Multiplan PHCS Seminole Tribe Employee PPO Seminole Tribe MCR ADV Simply Health MCD ADV Staywell Healthy Kids MCD ADV Sunshine State HP MCD ADV UHC UHC MCR ADV HMO/PPO UPMC Commercial UPMC MCR ADV VA Community Care Network Vivida MCD ADV Wellcare MCD ADV
MIU 10060 Drainage Of Skin Abscess CLAIM
IP/OP 727 290.8 166.73 1067 436.2 617.95 166.73 654.3 173 173 173 173 494.36 414.39 617.95 168.4 436.2 1067 168.4 508.9 N/A 617.95 617.95 166.73 N/A N/A N/A 341.69 168.4 363.5 175.07 166.73 N/A N/A

10060
0516 Clinic: Urgent care clinic
Included
















































































































MIU 12001 Repair Of Wounds, 2.5 cm Or Less CLAIM
IP/OP 486.86 194.744 110.62 1067 292.12 413.83 110.62 438.17 195 195 195 195 331.06 277.51 413.83 111.73 292.12 1067 111.73 340.8 N/A 413.83 413.83 110.62 N/A N/A N/A 228.82 111.73 243.43 116.15 110.62 N/A N/A

12001
0516 Clinic: Urgent care clinic
Included

































12001
0636 Drugs Require Specific ID: Drugs requiring detail coding
Included
















































































































MIU 12002 Repair Of Wounds, 2.6 cm-7.5 cm CLAIM
IP/OP 447 178.8 110.62 1067 268.2 379.95 110.62 402.3 184 184 184 184 303.96 254.79 379.95 111.73 268.2 1067 111.73 312.9 N/A 379.95 379.95 110.62 N/A N/A N/A 210.09 111.73 223.5 116.15 110.62 N/A N/A

12002
0516 Clinic: Urgent care clinic
Included
















































































































MIU 12011 Repair of wound (2.5 cm or less) of the face CLAIM
IP/OP 447 178.8 110.62 1067 268.2 379.95 110.62 402.3 184 184 184 184 303.96 254.79 379.95 111.73 268.2 1067 111.73 312.9 N/A 379.95 379.95 110.62 N/A N/A N/A 210.09 111.73 223.5 116.15 110.62 N/A N/A

12011
0516 Clinic: Urgent care clinic
Included
















































































































MIU 29125 Application of non-moveable, short arm splint CLAIM
IP/OP 1756.52 702.608 110.62 1600.5 1053.91 1493.04 110.62 1580.87 N/A N/A N/A N/A 1194.43 1001.22 1493.04 111.73 1053.91 1600.5 111.73 1229.56 N/A 1493.04 1493.04 110.62 N/A N/A N/A 825.56 111.73 878.26 116.15 110.62 N/A N/A

29125
0250 Pharmacy
Included

































29125
0301 Laboratory - Clinical Diagnostic: Chemistry
Included

































29125
0320 Radiology - Diagnostic
Included

































29125
0516 Clinic: Urgent care clinic
Included
















































































































MIU 51798 Ultrasound measurement of bladder capacity CLAIM
IP/OP 1352 540.8 110.62 1600.5 811.2 1149.2 110.62 1216.8 169 169 169 169 919.36 770.64 1149.2 111.73 811.2 1600.5 111.73 946.4 N/A 1149.2 1149.2 110.62 N/A N/A N/A 635.44 111.73 676 116.15 110.62 N/A N/A

51798
0306 Laboratory - Clinical Diagnostic: Bacteriology/microbiology
Included

































51798
0307 Laboratory - Clinical Diagnostic: Urology
Included

































51798
0360 Operating Room Services
Included

































51798
0516 Clinic: Urgent care clinic
Included
















































































































MIU 70450 CT Scan Head/Brain W/O Contrast CLAIM
IP/OP 4885 1954 106.95 4396.5 2931 4152.25 106.95 4396.5 1354 1456 1610 1682 3321.8 2784.45 4152.25 108.02 2931 3175.25 108.02 3419.5 N/A 4152.25 4152.25 106.95 N/A N/A N/A 2035.57 108.02 2442.5 112.3 106.95 N/A N/A

70450
0306 Laboratory - Clinical Diagnostic: Bacteriology/microbiology
Included

































70450
0351 CT Scan: Head
Included

































70450
0516 Clinic: Urgent care clinic
Included
















































































































MIU 70486 CT Scan Facial Bones W/O Contrast CLAIM
IP/OP 1839 735.6 106.95 1655.1 1103.4 1563.15 106.95 1655.1 1172 1274 1428 1500 1250.52 1048.23 1563.15 108.02 1103.4 1195.35 108.02 1287.3 N/A 1563.15 1563.15 106.95 N/A N/A N/A 864.33 108.02 919.5 112.3 106.95 N/A N/A

70486
0351 CT Scan: Head
Included
















































































































MIU 71045 X-Ray Chest 1 View CLAIM
IP/OP 420 168 76.15 420 252 357 76.15 378 420 420 420 420 285.6 239.4 357 76.92 252 273 76.92 294 N/A 357 357 76.15 N/A N/A N/A 197.4 76.92 210 79.96 76.15 N/A N/A

71045
0324 Radiology - Diagnostic: Chest X-ray
Included
















































































































MIU 71046 X-Ray Chest 2 View CLAIM
IP/OP 527 210.8 76.15 527 316.2 447.95 76.15 474.3 525 527 527 527 358.36 300.39 447.95 76.92 316.2 342.55 76.92 368.9 N/A 447.95 447.95 76.15 N/A N/A N/A 247.69 76.92 263.5 79.96 76.15 N/A N/A

71046
0324 Radiology - Diagnostic: Chest X-ray
Included
















































































































MIU 71250 CT Scan Chest W/O Contrast CLAIM
IP/OP 4240 1696 183.11 3816 2544 3604 183.11 3816 1697 1801 1955 2027 2883.2 2416.8 3604 184.94 2544 2756 184.94 2968 N/A 3604 3604 183.11 N/A N/A N/A 1732.42 184.94 2120 192.26 183.11 N/A N/A

71250
0324 Radiology - Diagnostic: Chest X-ray
Included

































71250
0352 CT Scan: Body
Included

































71250
0516 Clinic: Urgent care clinic
Included
















































































































MIU 71260 CT Scan Chest W Contrast CLAIM
IP/OP 5435 2174 173.88 4891.5 3261 4619.75 173.88 4891.5 1172 1274 1428 1500 3695.8 3097.95 4619.75 175.62 3261 3532.75 175.62 3804.5 N/A 4619.75 4619.75 173.88 N/A N/A N/A 2445.45 175.62 2717.5 182.57 173.88 N/A N/A

71260
0352 CT Scan: Body
Included

































71260
0636 Drugs Require Specific ID: Drugs requiring detail coding
Included
















































































































MIU 72040 X-Ray Cervical Spine 2 Or 3 Views CLAIM
IP/OP 1001 400.4 76.15 900.9 600.6 850.85 76.15 900.9 646 703 785 820 680.68 570.57 850.85 76.92 600.6 650.65 76.92 700.7 N/A 850.85 850.85 76.15 N/A N/A N/A 470.47 76.92 500.5 79.96 76.15 N/A N/A

72040
0320 Radiology - Diagnostic
Included
















































































































MIU 72100 X-Ray Lumbosacral Spine 4+ Views CLAIM
IP/OP 885 354 106.95 820 531 752.25 106.95 796.5 646 703 785 820 601.8 504.45 752.25 108.02 531 575.25 108.02 619.5 N/A 752.25 752.25 106.95 N/A N/A N/A 415.95 108.02 442.5 112.3 106.95 N/A N/A

72100
0320 Radiology - Diagnostic
Included
















































































































MIU 72110 X-Ray Lumbosacral Spine 2-3 Views CLAIM
IP/OP 1587 634.8 106.95 1428.3 952.2 1348.95 106.95 1428.3 646 703 785 820 1079.16 904.59 1348.95 108.02 952.2 1031.55 108.02 1110.9 N/A 1348.95 1348.95 106.95 N/A N/A N/A 745.89 108.02 793.5 112.3 106.95 N/A N/A

72110
0320 Radiology - Diagnostic
Included
















































































































MIU 72125 CT Cervical Spine W/O Contrast CLAIM
IP/OP 15943.36 6377.344 230.96 14349.02 9566.02 13551.86 230.96 14349.02 3516 3822 4284 4500 10841.48 9087.72 13551.86 233.27 9566.02 10363.18 233.27 11160.35 N/A 13551.86 13551.86 230.96 N/A N/A N/A 7148.97 233.27 7971.68 242.51 230.96 N/A N/A

72125
0351 CT Scan: Head
Included

































72125
0352 CT Scan: Body
Included

































72125
0516 Clinic: Urgent care clinic
Included

































72125
0636 Drugs Require Specific ID: Drugs requiring detail coding
Included

































72125
0771 Preventive Care Services: Admin. of vaccine
Included
















































































































MIU 72131 CT Lumbar Spine W/O Contrast CLAIM
IP/OP 5078 2031.2 106.95 4570.2 3046.8 4316.3 106.95 4570.2 1424 1526 1680 1752 3453.04 2894.46 4316.3 108.02 3046.8 3300.7 108.02 3554.6 N/A 4316.3 4316.3 106.95 N/A N/A N/A 2126.28 108.02 2539 112.3 106.95 N/A N/A

72131
0300 Laboratory - Clinical Diagnostic
Included

































72131
0307 Laboratory - Clinical Diagnostic: Urology
Included

































72131
0352 CT Scan: Body
Included

































72131
0516 Clinic: Urgent care clinic
Included
















































































































MIU 73030 X-Ray Shoulder Minimum 2 Views CLAIM
IP/OP 985 394 76.15 886.5 591 837.25 76.15 886.5 646 703 785 820 669.8 561.45 837.25 76.92 591 640.25 76.92 689.5 N/A 837.25 837.25 76.15 N/A N/A N/A 462.95 76.92 492.5 79.96 76.15 N/A N/A

73030
0320 Radiology - Diagnostic
Included
















































































































MIU 73080 X-Ray Elbow Minimum 3 Views CLAIM
IP/OP 1507 602.8 110.62 1356.3 904.2 1280.95 110.62 1356.3 646 703 785 820 1024.76 858.99 1280.95 111.73 904.2 979.55 111.73 1054.9 N/A 1280.95 1280.95 110.62 N/A N/A N/A 447.91 111.73 753.5 116.15 110.62 N/A N/A

73080
0320 Radiology - Diagnostic
Included

































73080
0516 Clinic: Urgent care clinic
Included
















































































































MIU 73090 X-Ray Forearm 2 Views CLAIM
IP/OP 2417 966.8 110.62 2175.3 1450.2 2054.45 110.62 2175.3 1292 1359 1441 1476 1643.56 1377.69 2054.45 111.73 1450.2 1571.05 111.73 1691.9 N/A 2054.45 2054.45 110.62 N/A N/A N/A 701.71 111.73 1208.5 116.15 110.62 N/A N/A

73090
0320 Radiology - Diagnostic
Included

































73090
0516 Clinic: Urgent care clinic
Included
















































































































MIU 73110 X-Ray Wrist Minimum 3 Views CLAIM
IP/OP 966 386.4 76.15 869.4 579.6 821.1 76.15 869.4 646 703 785 820 656.88 550.62 821.1 76.92 579.6 627.9 76.92 676.2 N/A 821.1 821.1 76.15 N/A N/A N/A 454.02 76.92 483 79.96 76.15 N/A N/A

73110
0320 Radiology - Diagnostic
Included
















































































































MIU 73130 X-Ray Hand Minimum 3 Views CLAIM
IP/OP 938 375.2 76.15 844.2 562.8 797.3 76.15 844.2 646 703 785 820 637.84 534.66 797.3 76.92 562.8 609.7 76.92 656.6 N/A 797.3 797.3 76.15 N/A N/A N/A 440.86 76.92 469 79.96 76.15 N/A N/A

73130
0320 Radiology - Diagnostic
Included
















































































































MIU 73502 X-Ray Hip2 To 3 Views CLAIM
IP/OP 554 221.6 76.15 554 332.4 470.9 76.15 498.6 554 554 554 554 376.72 315.78 470.9 76.92 332.4 360.1 76.92 387.8 N/A 470.9 470.9 76.15 N/A N/A N/A 260.38 76.92 277 79.96 76.15 N/A N/A

73502
0320 Radiology - Diagnostic
Included