|
GRFG AUTOL FAT LIPO 50 CC/<
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
76102620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$377.28 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$382.86
|
| Rate for Payer: Anthem Medicaid |
$377.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$680.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Humana Medicaid |
$377.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$620.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.83
|
| Rate for Payer: Molina Healthcare Passport |
$377.28
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$476.00
|
| Rate for Payer: UHCCP Medicaid |
$402.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.05
|
|
|
GRFG AUTOL FAT LIPO EA ADDL
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 15772
|
| Hospital Charge Code |
761P2627
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$113.13 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$113.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Humana Medicaid |
$113.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.39
|
| Rate for Payer: Molina Healthcare Passport |
$113.13
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.26
|
|
|
GRFG AUTOL FAT LIPO EA ADDL
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
HCPCS 15772
|
| Hospital Charge Code |
76102627
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$265.65
|
| Rate for Payer: Anthem Medicaid |
$118.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.10
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$286.35
|
| Rate for Payer: First Health Commercial |
$327.75
|
| Rate for Payer: Humana Commercial |
$293.25
|
| Rate for Payer: Humana KY Medicaid |
$118.65
|
| Rate for Payer: Kentucky WC Medicaid |
$119.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$254.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$121.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$303.60
|
| Rate for Payer: Ohio Health Group HMO |
$258.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$331.20
|
| Rate for Payer: United Healthcare All Payer |
$303.60
|
|
|
GRFG AUTOL FAT LIPO EA ADDL
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 15772
|
| Hospital Charge Code |
76102627
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$113.13 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$113.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Humana Medicaid |
$113.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.39
|
| Rate for Payer: Molina Healthcare Passport |
$113.13
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.26
|
|
|
GRFG AUTOL FAT LIPO EA ADDL
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
HCPCS 15772
|
| Hospital Charge Code |
76102627
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$265.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.10
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$286.35
|
| Rate for Payer: First Health Commercial |
$327.75
|
| Rate for Payer: Humana Commercial |
$293.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$254.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$303.60
|
| Rate for Payer: Ohio Health Group HMO |
$258.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$331.20
|
| Rate for Payer: United Healthcare All Payer |
$303.60
|
|
|
GRFG AUTOL SOFT TISS DIR EXC
|
Professional
|
Both
|
$6,547.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
76102710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$379.72 |
| Max. Negotiated Rate |
$6,547.00 |
| Rate for Payer: Anthem Medicaid |
$379.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,547.00
|
| Rate for Payer: Cash Price |
$3,273.50
|
| Rate for Payer: Cash Price |
$3,273.50
|
| Rate for Payer: Humana Medicaid |
$379.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$624.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.31
|
| Rate for Payer: Molina Healthcare Passport |
$379.72
|
| Rate for Payer: Multiplan PHCS |
$3,928.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,582.90
|
| Rate for Payer: UHCCP Medicaid |
$2,291.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.52
|
|
|
GRFG AUTOL SOFT TISS DIR EXC
|
Facility
|
IP
|
$6,547.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
76102710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$851.11 |
| Max. Negotiated Rate |
$6,285.12 |
| Rate for Payer: Aetna Commercial |
$5,041.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,106.66
|
| Rate for Payer: Cash Price |
$3,273.50
|
| Rate for Payer: Cigna Commercial |
$5,434.01
|
| Rate for Payer: First Health Commercial |
$6,219.65
|
| Rate for Payer: Humana Commercial |
$5,564.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,368.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,831.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,964.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,761.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,910.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,309.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$851.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.57
|
| Rate for Payer: PHCS Commercial |
$6,285.12
|
| Rate for Payer: United Healthcare All Payer |
$5,761.36
|
|
|
GRFG AUTOL SOFT TISS DIR EXC
|
Facility
|
OP
|
$6,547.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
76102710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$851.11 |
| Max. Negotiated Rate |
$6,285.12 |
| Rate for Payer: Aetna Commercial |
$5,041.19
|
| Rate for Payer: Anthem Medicaid |
$2,251.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,106.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,273.50
|
| Rate for Payer: Cash Price |
$3,273.50
|
| Rate for Payer: Cigna Commercial |
$5,434.01
|
| Rate for Payer: First Health Commercial |
$6,219.65
|
| Rate for Payer: Humana Commercial |
$5,564.95
|
| Rate for Payer: Humana KY Medicaid |
$2,251.51
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,274.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,368.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,831.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,296.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,761.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,910.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,309.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$851.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.57
|
| Rate for Payer: PHCS Commercial |
$6,285.12
|
| Rate for Payer: United Healthcare All Payer |
$5,761.36
|
|
|
GRFG AUTOL SOFT TISS DIR EXC(P
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
761P2710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$675.00 |
| Rate for Payer: Anthem Medicaid |
$379.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$675.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Humana Medicaid |
$379.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$624.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.31
|
| Rate for Payer: Molina Healthcare Passport |
$379.72
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$472.50
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.52
|
|
|
GRFG AUTOL SOFT TISS DIR EXC(T
|
Facility
|
OP
|
$5,872.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
761T2710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$763.36 |
| Max. Negotiated Rate |
$5,637.12 |
| Rate for Payer: Aetna Commercial |
$4,521.44
|
| Rate for Payer: Anthem Medicaid |
$2,019.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,580.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,936.00
|
| Rate for Payer: Cash Price |
$2,936.00
|
| Rate for Payer: Cigna Commercial |
$4,873.76
|
| Rate for Payer: First Health Commercial |
$5,578.40
|
| Rate for Payer: Humana Commercial |
$4,991.20
|
| Rate for Payer: Humana KY Medicaid |
$2,019.38
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,039.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,815.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,333.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,059.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,167.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,404.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$763.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,820.32
|
| Rate for Payer: PHCS Commercial |
$5,637.12
|
| Rate for Payer: United Healthcare All Payer |
$5,167.36
|
|
|
GRFG AUTOL SOFT TISS DIR EXC(T
|
Facility
|
IP
|
$5,872.00
|
|
|
Service Code
|
HCPCS 15769
|
| Hospital Charge Code |
761T2710
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$763.36 |
| Max. Negotiated Rate |
$5,637.12 |
| Rate for Payer: Aetna Commercial |
$4,521.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,580.16
|
| Rate for Payer: Cash Price |
$2,936.00
|
| Rate for Payer: Cigna Commercial |
$4,873.76
|
| Rate for Payer: First Health Commercial |
$5,578.40
|
| Rate for Payer: Humana Commercial |
$4,991.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,815.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,333.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,761.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,167.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,404.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$763.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,820.32
|
| Rate for Payer: PHCS Commercial |
$5,637.12
|
| Rate for Payer: United Healthcare All Payer |
$5,167.36
|
|
|
GRFT AX-BYFEM STD W/RING 90*40
|
Facility
|
IP
|
$12,344.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.81 |
| Max. Negotiated Rate |
$11,850.91 |
| Rate for Payer: Aetna Commercial |
$9,505.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,628.87
|
| Rate for Payer: Cash Price |
$6,172.35
|
| Rate for Payer: Cigna Commercial |
$10,246.10
|
| Rate for Payer: First Health Commercial |
$11,727.46
|
| Rate for Payer: Humana Commercial |
$10,493.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,122.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,110.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,703.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,863.34
|
| Rate for Payer: Ohio Health Group HMO |
$9,258.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,468.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,826.86
|
| Rate for Payer: PHCS Commercial |
$11,850.91
|
| Rate for Payer: United Healthcare All Payer |
$10,863.34
|
|
|
GRFT AX-BYFEM STD W/RING 90*40
|
Facility
|
OP
|
$12,344.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.81 |
| Max. Negotiated Rate |
$11,850.91 |
| Rate for Payer: Aetna Commercial |
$9,505.42
|
| Rate for Payer: Anthem Medicaid |
$4,245.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,628.87
|
| Rate for Payer: Cash Price |
$6,172.35
|
| Rate for Payer: Cigna Commercial |
$10,246.10
|
| Rate for Payer: First Health Commercial |
$11,727.46
|
| Rate for Payer: Humana Commercial |
$10,493.00
|
| Rate for Payer: Humana KY Medicaid |
$4,245.34
|
| Rate for Payer: Kentucky WC Medicaid |
$4,288.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,122.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,110.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,703.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,330.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,863.34
|
| Rate for Payer: Ohio Health Group HMO |
$9,258.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,468.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,826.86
|
| Rate for Payer: PHCS Commercial |
$11,850.91
|
| Rate for Payer: United Healthcare All Payer |
$10,863.34
|
|
|
GRIS-PEG 250MG TABLET
|
Facility
|
OP
|
$22.10
|
|
|
Service Code
|
NDC 115172501
|
| Hospital Charge Code |
25000740
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$21.22 |
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Anthem Medicaid |
$7.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.24
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cigna Commercial |
$18.34
|
| Rate for Payer: First Health Commercial |
$21.00
|
| Rate for Payer: Humana Commercial |
$18.78
|
| Rate for Payer: Humana KY Medicaid |
$7.60
|
| Rate for Payer: Kentucky WC Medicaid |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.45
|
| Rate for Payer: Ohio Health Group HMO |
$16.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.85
|
| Rate for Payer: PHCS Commercial |
$21.22
|
| Rate for Payer: United Healthcare All Payer |
$19.45
|
|
|
GRIS-PEG 250MG TABLET
|
Facility
|
IP
|
$22.10
|
|
|
Service Code
|
NDC 115172501
|
| Hospital Charge Code |
25000740
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$21.22 |
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.24
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cigna Commercial |
$18.34
|
| Rate for Payer: First Health Commercial |
$21.00
|
| Rate for Payer: Humana Commercial |
$18.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.45
|
| Rate for Payer: Ohio Health Group HMO |
$16.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.85
|
| Rate for Payer: PHCS Commercial |
$21.22
|
| Rate for Payer: United Healthcare All Payer |
$19.45
|
|
|
GROIN SOFT TISSUE US LTD
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.94 |
| Max. Negotiated Rate |
$804.48 |
| Rate for Payer: Aetna Commercial |
$645.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$653.64
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$695.54
|
| Rate for Payer: First Health Commercial |
$796.10
|
| Rate for Payer: Humana Commercial |
$712.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.44
|
| Rate for Payer: Ohio Health Group HMO |
$628.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.78
|
| Rate for Payer: PHCS Commercial |
$804.48
|
| Rate for Payer: United Healthcare All Payer |
$737.44
|
|
|
GROIN SOFT TISSUE US LTD
|
Professional
|
Both
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$838.00 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$838.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$50.74
|
| Rate for Payer: Healthspan PPO |
$33.70
|
| Rate for Payer: Humana Medicaid |
$26.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$502.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$586.60
|
| Rate for Payer: UHCCP Medicaid |
$293.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
|
|
GROIN SOFT TISSUE US LTD
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$804.48 |
| Rate for Payer: Aetna Commercial |
$645.26
|
| Rate for Payer: Anthem Medicaid |
$288.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$653.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$695.54
|
| Rate for Payer: First Health Commercial |
$796.10
|
| Rate for Payer: Humana Commercial |
$712.30
|
| Rate for Payer: Humana KY Medicaid |
$288.19
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$291.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$293.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.44
|
| Rate for Payer: Ohio Health Group HMO |
$628.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.78
|
| Rate for Payer: PHCS Commercial |
$804.48
|
| Rate for Payer: United Healthcare All Payer |
$737.44
|
|
|
GROIN SOFT TISSUE US LTD(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402P0057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$50.74
|
| Rate for Payer: Healthspan PPO |
$33.70
|
| Rate for Payer: Humana Medicaid |
$26.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
|
|
GROIN SOFT TISSUE US LTD(T
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
GROIN SOFT TISSUE US LTD(T
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0057
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
GROLLMAN PIGTAIL 7F
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.04 |
| Max. Negotiated Rate |
$487.68 |
| Rate for Payer: Aetna Commercial |
$391.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$396.24
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cigna Commercial |
$421.64
|
| Rate for Payer: First Health Commercial |
$482.60
|
| Rate for Payer: Humana Commercial |
$431.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$416.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.04
|
| Rate for Payer: Ohio Health Group HMO |
$381.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$157.48
|
| Rate for Payer: PHCS Commercial |
$487.68
|
| Rate for Payer: United Healthcare All Payer |
$447.04
|
|
|
GROLLMAN PIGTAIL 7F
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.04 |
| Max. Negotiated Rate |
$487.68 |
| Rate for Payer: Aetna Commercial |
$391.16
|
| Rate for Payer: Anthem Medicaid |
$174.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$396.24
|
| Rate for Payer: Cash Price |
$254.00
|
| Rate for Payer: Cigna Commercial |
$421.64
|
| Rate for Payer: First Health Commercial |
$482.60
|
| Rate for Payer: Humana Commercial |
$431.80
|
| Rate for Payer: Humana KY Medicaid |
$174.70
|
| Rate for Payer: Kentucky WC Medicaid |
$176.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$416.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.04
|
| Rate for Payer: Ohio Health Group HMO |
$381.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$157.48
|
| Rate for Payer: PHCS Commercial |
$487.68
|
| Rate for Payer: United Healthcare All Payer |
$447.04
|
|
|
GROUP A STREPTOCOCCUS CULTURE
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001265
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem Medicaid |
$6.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.63
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Humana KY Medicaid |
$6.63
|
| Rate for Payer: Humana Medicare Advantage |
$6.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.69
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
|
GROUP A STREPTOCOCCUS CULTURE
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001265
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$95.04 |
| Rate for Payer: Aetna Commercial |
$76.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.50
|
| Rate for Payer: Cash Price |
$49.50
|
| Rate for Payer: Cigna Commercial |
$82.17
|
| Rate for Payer: First Health Commercial |
$94.05
|
| Rate for Payer: Humana Commercial |
$84.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$87.12
|
| Rate for Payer: Ohio Health Group HMO |
$74.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.69
|
| Rate for Payer: PHCS Commercial |
$95.04
|
| Rate for Payer: United Healthcare All Payer |
$87.12
|
|
