|
FULL THICKNESS GRAFT - CLOSU(T
|
Facility
|
OP
|
$4,085.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761T0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,405.06 |
| Max. Negotiated Rate |
$3,922.22 |
| Rate for Payer: Aetna Commercial |
$3,145.95
|
| Rate for Payer: Anthem Medicaid |
$1,405.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cigna Commercial |
$3,391.09
|
| Rate for Payer: First Health Commercial |
$3,881.37
|
| Rate for Payer: Humana Commercial |
$3,472.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,419.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,350.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,015.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,433.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,595.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,064.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,268.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,554.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,819.10
|
| Rate for Payer: PHCS Commercial |
$3,922.22
|
| Rate for Payer: United Healthcare All Payer |
$3,595.37
|
|
|
FULL THICKNESS GRAFT(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761P0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.52 |
| Max. Negotiated Rate |
$1,207.11 |
| Rate for Payer: Aetna Commercial |
$1,207.11
|
| Rate for Payer: Ambetter Exchange |
$792.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$426.52
|
| Rate for Payer: Anthem Medicaid |
$504.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$792.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$792.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$951.29
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,128.38
|
| Rate for Payer: Healthspan PPO |
$1,097.43
|
| Rate for Payer: Humana Medicaid |
$504.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,080.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$792.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$792.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$514.76
|
| Rate for Payer: Molina Healthcare Passport |
$504.67
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,030.56
|
| Rate for Payer: UHCCP Medicaid |
$447.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$509.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$792.74
|
|
|
FULL THICKNESS GRAFT(T
|
Facility
|
OP
|
$4,380.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761T0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,506.40 |
| Max. Negotiated Rate |
$4,205.12 |
| Rate for Payer: Aetna Commercial |
$3,372.85
|
| Rate for Payer: Anthem Medicaid |
$1,506.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,416.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cigna Commercial |
$3,635.67
|
| Rate for Payer: First Health Commercial |
$4,161.31
|
| Rate for Payer: Humana Commercial |
$3,723.28
|
| Rate for Payer: Humana KY Medicaid |
$1,506.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,521.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,591.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,232.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,536.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,854.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,285.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,504.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,810.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,022.43
|
| Rate for Payer: PHCS Commercial |
$4,205.12
|
| Rate for Payer: United Healthcare All Payer |
$3,854.69
|
|
|
FULL THICKNESS GRAFT(T
|
Facility
|
IP
|
$4,380.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
761T0188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,314.10 |
| Max. Negotiated Rate |
$4,205.12 |
| Rate for Payer: Aetna Commercial |
$3,372.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,416.66
|
| Rate for Payer: Cash Price |
$2,190.16
|
| Rate for Payer: Cigna Commercial |
$3,635.67
|
| Rate for Payer: First Health Commercial |
$4,161.31
|
| Rate for Payer: Humana Commercial |
$3,723.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,591.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,232.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,314.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,854.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,285.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,504.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,810.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,022.43
|
| Rate for Payer: PHCS Commercial |
$4,205.12
|
| Rate for Payer: United Healthcare All Payer |
$3,854.69
|
|
|
FULLY ARTICULATING CATHETER
|
Facility
|
IP
|
$34,250.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10,275.00 |
| Max. Negotiated Rate |
$32,880.00 |
| Rate for Payer: Aetna Commercial |
$26,372.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,715.00
|
| Rate for Payer: Cash Price |
$17,125.00
|
| Rate for Payer: Cigna Commercial |
$28,427.50
|
| Rate for Payer: First Health Commercial |
$32,537.50
|
| Rate for Payer: Humana Commercial |
$29,112.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,085.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,276.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,140.00
|
| Rate for Payer: Ohio Health Group HMO |
$25,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,797.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,632.50
|
| Rate for Payer: PHCS Commercial |
$32,880.00
|
| Rate for Payer: United Healthcare All Payer |
$30,140.00
|
|
|
FULLY ARTICULATING CATHETER
|
Facility
|
OP
|
$34,250.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10,275.00 |
| Max. Negotiated Rate |
$32,880.00 |
| Rate for Payer: Aetna Commercial |
$26,372.50
|
| Rate for Payer: Anthem Medicaid |
$11,778.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,715.00
|
| Rate for Payer: Cash Price |
$17,125.00
|
| Rate for Payer: Cigna Commercial |
$28,427.50
|
| Rate for Payer: First Health Commercial |
$32,537.50
|
| Rate for Payer: Humana Commercial |
$29,112.50
|
| Rate for Payer: Humana KY Medicaid |
$11,778.58
|
| Rate for Payer: Kentucky WC Medicaid |
$11,898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,085.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,276.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,014.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,140.00
|
| Rate for Payer: Ohio Health Group HMO |
$25,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,797.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,632.50
|
| Rate for Payer: PHCS Commercial |
$32,880.00
|
| Rate for Payer: United Healthcare All Payer |
$30,140.00
|
|
|
FULPHILA 6MG/0.6ML SYR
|
Facility
|
OP
|
$11,376.88
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
25002733
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.71 |
| Max. Negotiated Rate |
$10,921.80 |
| Rate for Payer: Aetna Commercial |
$8,760.20
|
| Rate for Payer: Anthem Medicaid |
$3,912.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$103.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,873.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$145.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$140.01
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cigna Commercial |
$9,442.81
|
| Rate for Payer: First Health Commercial |
$10,808.04
|
| Rate for Payer: Humana Commercial |
$9,670.35
|
| Rate for Payer: Humana KY Medicaid |
$3,912.51
|
| Rate for Payer: Humana Medicare Advantage |
$103.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3,952.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,329.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,396.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,991.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,011.65
|
| Rate for Payer: Ohio Health Group HMO |
$8,532.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,101.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,897.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,850.05
|
| Rate for Payer: PHCS Commercial |
$10,921.80
|
| Rate for Payer: United Healthcare All Payer |
$10,011.65
|
|
|
FULPHILA 6MG/0.6ML SYR
|
Facility
|
IP
|
$11,376.88
|
|
|
Service Code
|
HCPCS Q5108
|
| Hospital Charge Code |
25002733
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,413.06 |
| Max. Negotiated Rate |
$10,921.80 |
| Rate for Payer: Aetna Commercial |
$8,760.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,873.97
|
| Rate for Payer: Cash Price |
$5,688.44
|
| Rate for Payer: Cigna Commercial |
$9,442.81
|
| Rate for Payer: First Health Commercial |
$10,808.04
|
| Rate for Payer: Humana Commercial |
$9,670.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,329.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,396.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,413.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,011.65
|
| Rate for Payer: Ohio Health Group HMO |
$8,532.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,101.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,897.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,850.05
|
| Rate for Payer: PHCS Commercial |
$10,921.80
|
| Rate for Payer: United Healthcare All Payer |
$10,011.65
|
|
|
FUNCTIONAL CAPACITY 15 MIN 1
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
43000030
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$33.90 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem Medicaid |
$38.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Humana KY Medicaid |
$38.86
|
| Rate for Payer: Kentucky WC Medicaid |
$39.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
FUNCTIONAL CAPACITY 15 MIN 1
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
43000030
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$33.90 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
FUNGIZONE (AMPHOTERI 50MG/10ML
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
25001858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$195.84 |
| Rate for Payer: Aetna Commercial |
$157.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.12
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$169.32
|
| Rate for Payer: First Health Commercial |
$193.80
|
| Rate for Payer: Humana Commercial |
$173.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.52
|
| Rate for Payer: Ohio Health Group HMO |
$153.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.76
|
| Rate for Payer: PHCS Commercial |
$195.84
|
| Rate for Payer: United Healthcare All Payer |
$179.52
|
|
|
FUNGIZONE (AMPHOTERI 50MG/10ML
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
HCPCS J0285
|
| Hospital Charge Code |
25001858
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$195.84 |
| Rate for Payer: Aetna Commercial |
$157.08
|
| Rate for Payer: Anthem Medicaid |
$70.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.12
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$169.32
|
| Rate for Payer: First Health Commercial |
$193.80
|
| Rate for Payer: Humana Commercial |
$173.40
|
| Rate for Payer: Humana KY Medicaid |
$70.16
|
| Rate for Payer: Kentucky WC Medicaid |
$70.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$150.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$179.52
|
| Rate for Payer: Ohio Health Group HMO |
$153.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.76
|
| Rate for Payer: PHCS Commercial |
$195.84
|
| Rate for Payer: United Healthcare All Payer |
$179.52
|
|
|
FUNGUS CULT - BLD W/ID ISOLATE
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 87103
|
| Hospital Charge Code |
30001275
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem Medicaid |
$20.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Humana KY Medicaid |
$20.46
|
| Rate for Payer: Humana Medicare Advantage |
$20.46
|
| Rate for Payer: Kentucky WC Medicaid |
$20.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
FUNGUS CULT - BLD W/ID ISOLATE
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 87103
|
| Hospital Charge Code |
30001275
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.63
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
FUNGUS PRESUMPTIVE IDENT
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
30001274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.08
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FUNGUS PRESUMPTIVE IDENT
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 87102
|
| Hospital Charge Code |
30001274
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$8.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.41
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$8.41
|
| Rate for Payer: Humana Medicare Advantage |
$8.41
|
| Rate for Payer: Kentucky WC Medicaid |
$8.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.08
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FUNGUS -SKINHAIRNAILS-W/ID ISO
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
HCPCS 87101
|
| Hospital Charge Code |
30001273
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.40 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.52
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
FUNGUS -SKINHAIRNAILS-W/ID ISO
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
HCPCS 87101
|
| Hospital Charge Code |
30001273
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$103.68 |
| Rate for Payer: Aetna Commercial |
$83.16
|
| Rate for Payer: Anthem Medicaid |
$7.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$86.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.71
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna Commercial |
$89.64
|
| Rate for Payer: First Health Commercial |
$102.60
|
| Rate for Payer: Humana Commercial |
$91.80
|
| Rate for Payer: Humana KY Medicaid |
$7.71
|
| Rate for Payer: Humana Medicare Advantage |
$7.71
|
| Rate for Payer: Kentucky WC Medicaid |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$88.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$79.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$95.04
|
| Rate for Payer: Ohio Health Group HMO |
$81.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.52
|
| Rate for Payer: PHCS Commercial |
$103.68
|
| Rate for Payer: United Healthcare All Payer |
$95.04
|
|
|
FUNGUS SMEAR ONLY W/INTERP.
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001325
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$4.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$4.27
|
| Rate for Payer: Humana Medicare Advantage |
$4.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
FUNGUS SMEAR ONLY W/INTERP.
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001325
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
FUROSEMIDE 1mg (100mg SDV)
|
Facility
|
IP
|
$77.57
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
25002201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$74.47 |
| Rate for Payer: Aetna Commercial |
$59.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.50
|
| Rate for Payer: Cash Price |
$38.78
|
| Rate for Payer: Cigna Commercial |
$64.38
|
| Rate for Payer: First Health Commercial |
$73.69
|
| Rate for Payer: Humana Commercial |
$65.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.26
|
| Rate for Payer: Ohio Health Group HMO |
$58.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.52
|
| Rate for Payer: PHCS Commercial |
$74.47
|
| Rate for Payer: United Healthcare All Payer |
$68.26
|
|
|
FUROSEMIDE 1mg (100mg SDV)
|
Facility
|
OP
|
$77.57
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
25002201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$74.47 |
| Rate for Payer: Aetna Commercial |
$59.73
|
| Rate for Payer: Anthem Medicaid |
$26.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.50
|
| Rate for Payer: Cash Price |
$38.78
|
| Rate for Payer: Cigna Commercial |
$64.38
|
| Rate for Payer: First Health Commercial |
$73.69
|
| Rate for Payer: Humana Commercial |
$65.93
|
| Rate for Payer: Humana KY Medicaid |
$26.68
|
| Rate for Payer: Kentucky WC Medicaid |
$26.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.26
|
| Rate for Payer: Ohio Health Group HMO |
$58.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.52
|
| Rate for Payer: PHCS Commercial |
$74.47
|
| Rate for Payer: United Healthcare All Payer |
$68.26
|
|
|
FUROSEMIDE 1mg (20mg SDV)
|
Facility
|
OP
|
$78.10
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
25002200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$74.98 |
| Rate for Payer: Aetna Commercial |
$60.14
|
| Rate for Payer: Anthem Medicaid |
$26.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.92
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna Commercial |
$64.82
|
| Rate for Payer: First Health Commercial |
$74.19
|
| Rate for Payer: Humana Commercial |
$66.39
|
| Rate for Payer: Humana KY Medicaid |
$26.86
|
| Rate for Payer: Kentucky WC Medicaid |
$27.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.73
|
| Rate for Payer: Ohio Health Group HMO |
$58.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.89
|
| Rate for Payer: PHCS Commercial |
$74.98
|
| Rate for Payer: United Healthcare All Payer |
$68.73
|
|
|
FUROSEMIDE 1mg (20mg SDV)
|
Facility
|
IP
|
$78.10
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
25002200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$74.98 |
| Rate for Payer: Aetna Commercial |
$60.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.92
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: Cigna Commercial |
$64.82
|
| Rate for Payer: First Health Commercial |
$74.19
|
| Rate for Payer: Humana Commercial |
$66.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.73
|
| Rate for Payer: Ohio Health Group HMO |
$58.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.89
|
| Rate for Payer: PHCS Commercial |
$74.98
|
| Rate for Payer: United Healthcare All Payer |
$68.73
|
|
|
FUROSEMIDE 1mg (40mg SDV)
|
Facility
|
OP
|
$78.90
|
|
|
Service Code
|
HCPCS J1938
|
| Hospital Charge Code |
25002199
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.67 |
| Max. Negotiated Rate |
$75.74 |
| Rate for Payer: Aetna Commercial |
$60.75
|
| Rate for Payer: Anthem Medicaid |
$27.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.54
|
| Rate for Payer: Cash Price |
$39.45
|
| Rate for Payer: Cigna Commercial |
$65.49
|
| Rate for Payer: First Health Commercial |
$74.95
|
| Rate for Payer: Humana Commercial |
$67.06
|
| Rate for Payer: Humana KY Medicaid |
$27.13
|
| Rate for Payer: Kentucky WC Medicaid |
$27.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.43
|
| Rate for Payer: Ohio Health Group HMO |
$59.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.44
|
| Rate for Payer: PHCS Commercial |
$75.74
|
| Rate for Payer: United Healthcare All Payer |
$69.43
|
|
