|
IN 111 PENETATE PER 0.5 MCI(T
|
Facility
|
IP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
340T0060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$164.71 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Cash Price |
$633.50
|
| Rate for Payer: Cigna Commercial |
$1,051.61
|
| Rate for Payer: First Health Commercial |
$1,203.65
|
| Rate for Payer: Humana Commercial |
$1,076.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,038.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$935.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$380.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,114.96
|
| Rate for Payer: Ohio Health Group HMO |
$950.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$253.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.77
|
| Rate for Payer: PHCS Commercial |
$1,216.32
|
| Rate for Payer: United Healthcare All Payer |
$1,114.96
|
|
|
IN 111 PENETATE PER 0.5 MCI(T
|
Facility
|
OP
|
$1,267.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
340T0060
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$164.71 |
| Max. Negotiated Rate |
$1,216.32 |
| Rate for Payer: Aetna Commercial |
$975.59
|
| Rate for Payer: Anthem Medicaid |
$435.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$988.26
|
| Rate for Payer: Cash Price |
$633.50
|
| Rate for Payer: Cigna Commercial |
$1,051.61
|
| Rate for Payer: First Health Commercial |
$1,203.65
|
| Rate for Payer: Humana Commercial |
$1,076.95
|
| Rate for Payer: Humana KY Medicaid |
$435.72
|
| Rate for Payer: Kentucky WC Medicaid |
$440.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,038.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$935.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$380.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$444.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,114.96
|
| Rate for Payer: Ohio Health Group HMO |
$950.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$253.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$392.77
|
| Rate for Payer: PHCS Commercial |
$1,216.32
|
| Rate for Payer: United Healthcare All Payer |
$1,114.96
|
|
|
INBORN AND OTHER DISORDERS OF METABOLISM
|
Facility
|
IP
|
$15,246.27
|
|
|
Service Code
|
MSDRG 642
|
| Min. Negotiated Rate |
$10,345.68 |
| Max. Negotiated Rate |
$15,246.27 |
| Rate for Payer: Anthem Medicaid |
$10,345.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,890.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,246.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,701.76
|
| Rate for Payer: Humana KY Medicaid |
$10,345.68
|
| Rate for Payer: Humana Medicare Advantage |
$10,890.19
|
| Rate for Payer: Kentucky WC Medicaid |
$10,449.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,068.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,552.59
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Professional
|
Both
|
$971.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$971.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.10
|
| Rate for Payer: Anthem Medicaid |
$26.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$971.00
|
| Rate for Payer: Cash Price |
$485.50
|
| Rate for Payer: Cash Price |
$485.50
|
| Rate for Payer: Cigna Commercial |
$114.39
|
| Rate for Payer: Humana Medicaid |
$26.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.60
|
| Rate for Payer: Molina Healthcare Passport |
$26.08
|
| Rate for Payer: Multiplan PHCS |
$582.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$679.70
|
| Rate for Payer: UHCCP Medicaid |
$25.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.34
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Facility
|
IP
|
$971.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.23 |
| Max. Negotiated Rate |
$932.16 |
| Rate for Payer: Aetna Commercial |
$747.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$757.38
|
| Rate for Payer: Cash Price |
$485.50
|
| Rate for Payer: Cigna Commercial |
$805.93
|
| Rate for Payer: First Health Commercial |
$922.45
|
| Rate for Payer: Humana Commercial |
$825.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$796.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$716.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$854.48
|
| Rate for Payer: Ohio Health Group HMO |
$728.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$194.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$301.01
|
| Rate for Payer: PHCS Commercial |
$932.16
|
| Rate for Payer: United Healthcare All Payer |
$854.48
|
|
|
INCAL BX SKN EA SEP/ADDL
|
Facility
|
OP
|
$971.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
76100036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.23 |
| Max. Negotiated Rate |
$932.16 |
| Rate for Payer: Aetna Commercial |
$747.67
|
| Rate for Payer: Anthem Medicaid |
$333.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$757.38
|
| Rate for Payer: Cash Price |
$485.50
|
| Rate for Payer: Cigna Commercial |
$805.93
|
| Rate for Payer: First Health Commercial |
$922.45
|
| Rate for Payer: Humana Commercial |
$825.35
|
| Rate for Payer: Humana KY Medicaid |
$333.93
|
| Rate for Payer: Kentucky WC Medicaid |
$337.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$796.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$716.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$340.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$854.48
|
| Rate for Payer: Ohio Health Group HMO |
$728.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$194.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$301.01
|
| Rate for Payer: PHCS Commercial |
$932.16
|
| Rate for Payer: United Healthcare All Payer |
$854.48
|
|
|
INCAL BX SKN EA SEP/ADDL(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
761P0036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.10
|
| Rate for Payer: Anthem Medicaid |
$26.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$114.39
|
| Rate for Payer: Humana Medicaid |
$26.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.60
|
| Rate for Payer: Molina Healthcare Passport |
$26.08
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$25.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.34
|
|
|
INCAL BX SKN EA SEP/ADDL(T
|
Facility
|
IP
|
$736.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
761T0036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.68 |
| Max. Negotiated Rate |
$706.56 |
| Rate for Payer: Aetna Commercial |
$566.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.08
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: First Health Commercial |
$699.20
|
| Rate for Payer: Humana Commercial |
$625.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$603.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$647.68
|
| Rate for Payer: Ohio Health Group HMO |
$552.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.16
|
| Rate for Payer: PHCS Commercial |
$706.56
|
| Rate for Payer: United Healthcare All Payer |
$647.68
|
|
|
INCAL BX SKN EA SEP/ADDL(T
|
Facility
|
OP
|
$736.00
|
|
|
Service Code
|
HCPCS 11107
|
| Hospital Charge Code |
761T0036
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.68 |
| Max. Negotiated Rate |
$706.56 |
| Rate for Payer: Aetna Commercial |
$566.72
|
| Rate for Payer: Anthem Medicaid |
$253.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.08
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: First Health Commercial |
$699.20
|
| Rate for Payer: Humana Commercial |
$625.60
|
| Rate for Payer: Humana KY Medicaid |
$253.11
|
| Rate for Payer: Kentucky WC Medicaid |
$255.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$603.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$647.68
|
| Rate for Payer: Ohio Health Group HMO |
$552.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.16
|
| Rate for Payer: PHCS Commercial |
$706.56
|
| Rate for Payer: United Healthcare All Payer |
$647.68
|
|
|
INCAL BX SKN SINGLE LES
|
Facility
|
IP
|
$1,424.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
76102569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.12 |
| Max. Negotiated Rate |
$1,367.04 |
| Rate for Payer: Aetna Commercial |
$1,096.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,110.72
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,181.92
|
| Rate for Payer: First Health Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial |
$1,210.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,167.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,050.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,253.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.44
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
INCAL BX SKN SINGLE LES
|
Professional
|
Both
|
$1,424.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
76102569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$1,424.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.78
|
| Rate for Payer: Anthem Medicaid |
$48.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,424.00
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$238.40
|
| Rate for Payer: Humana Medicaid |
$48.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.75
|
| Rate for Payer: Molina Healthcare Passport |
$48.77
|
| Rate for Payer: Multiplan PHCS |
$854.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$996.80
|
| Rate for Payer: UHCCP Medicaid |
$40.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.26
|
|
|
INCAL BX SKN SINGLE LES
|
Facility
|
OP
|
$1,424.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
76102569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.12 |
| Max. Negotiated Rate |
$1,367.04 |
| Rate for Payer: Aetna Commercial |
$1,096.48
|
| Rate for Payer: Anthem Medicaid |
$489.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,110.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cash Price |
$712.00
|
| Rate for Payer: Cigna Commercial |
$1,181.92
|
| Rate for Payer: First Health Commercial |
$1,352.80
|
| Rate for Payer: Humana Commercial |
$1,210.40
|
| Rate for Payer: Humana KY Medicaid |
$489.71
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$494.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,167.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,050.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$499.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,253.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.44
|
| Rate for Payer: PHCS Commercial |
$1,367.04
|
| Rate for Payer: United Healthcare All Payer |
$1,253.12
|
|
|
INCAL BX SKN SINGLE LES(P
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
761P2569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.78 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.78
|
| Rate for Payer: Anthem Medicaid |
$48.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$238.40
|
| Rate for Payer: Humana Medicaid |
$48.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.75
|
| Rate for Payer: Molina Healthcare Passport |
$48.77
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$40.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.26
|
|
|
INCAL BX SKN SINGLE LES(T
|
Facility
|
OP
|
$1,164.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
761T2569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$151.32 |
| Max. Negotiated Rate |
$1,117.44 |
| Rate for Payer: Aetna Commercial |
$896.28
|
| Rate for Payer: Anthem Medicaid |
$400.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$907.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cigna Commercial |
$966.12
|
| Rate for Payer: First Health Commercial |
$1,105.80
|
| Rate for Payer: Humana Commercial |
$989.40
|
| Rate for Payer: Humana KY Medicaid |
$400.30
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$404.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$954.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$859.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$408.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,024.32
|
| Rate for Payer: Ohio Health Group HMO |
$873.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.84
|
| Rate for Payer: PHCS Commercial |
$1,117.44
|
| Rate for Payer: United Healthcare All Payer |
$1,024.32
|
|
|
INCAL BX SKN SINGLE LES(T
|
Facility
|
IP
|
$1,164.00
|
|
|
Service Code
|
HCPCS 11106
|
| Hospital Charge Code |
761T2569
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$151.32 |
| Max. Negotiated Rate |
$1,117.44 |
| Rate for Payer: Aetna Commercial |
$896.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$907.92
|
| Rate for Payer: Cash Price |
$582.00
|
| Rate for Payer: Cigna Commercial |
$966.12
|
| Rate for Payer: First Health Commercial |
$1,105.80
|
| Rate for Payer: Humana Commercial |
$989.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$954.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$859.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$349.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,024.32
|
| Rate for Payer: Ohio Health Group HMO |
$873.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.84
|
| Rate for Payer: PHCS Commercial |
$1,117.44
|
| Rate for Payer: United Healthcare All Payer |
$1,024.32
|
|
|
INCARC OBTURATOR HERNIA RPR
|
Facility
|
IP
|
$2,450.00
|
|
|
Service Code
|
HCPCS 49999
|
| Hospital Charge Code |
76102043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.50 |
| Max. Negotiated Rate |
$2,352.00 |
| Rate for Payer: Aetna Commercial |
$1,886.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,911.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Cigna Commercial |
$2,033.50
|
| Rate for Payer: First Health Commercial |
$2,327.50
|
| Rate for Payer: Humana Commercial |
$2,082.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,009.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,808.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$735.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,156.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$318.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.50
|
| Rate for Payer: PHCS Commercial |
$2,352.00
|
| Rate for Payer: United Healthcare All Payer |
$2,156.00
|
|
|
INCARC OBTURATOR HERNIA RPR
|
Professional
|
Both
|
$2,450.00
|
|
|
Service Code
|
HCPCS 49999
|
| Hospital Charge Code |
76102043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,450.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,450.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,470.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,715.00
|
| Rate for Payer: UHCCP Medicaid |
$857.50
|
|
|
INCARC OBTURATOR HERNIA RPR
|
Facility
|
OP
|
$2,450.00
|
|
|
Service Code
|
HCPCS 49999
|
| Hospital Charge Code |
76102043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.50 |
| Max. Negotiated Rate |
$2,352.00 |
| Rate for Payer: Aetna Commercial |
$1,886.50
|
| Rate for Payer: Anthem Medicaid |
$842.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,911.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Cigna Commercial |
$2,033.50
|
| Rate for Payer: First Health Commercial |
$2,327.50
|
| Rate for Payer: Humana Commercial |
$2,082.50
|
| Rate for Payer: Humana KY Medicaid |
$842.56
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$851.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,009.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,808.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$859.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,156.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$318.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.50
|
| Rate for Payer: PHCS Commercial |
$2,352.00
|
| Rate for Payer: United Healthcare All Payer |
$2,156.00
|
|
|
INCARC OBTURATOR HERNIA RPR(P
|
Professional
|
Both
|
$2,450.00
|
|
|
Service Code
|
HCPCS 49999
|
| Hospital Charge Code |
761P2043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,450.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,450.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Cash Price |
$1,225.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,470.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,715.00
|
| Rate for Payer: UHCCP Medicaid |
$857.50
|
|
|
INC/DRAINAGE DEEP ABSCESS
|
Professional
|
Both
|
$6,975.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
76100390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.42 |
| Max. Negotiated Rate |
$6,975.00 |
| Rate for Payer: Aetna Commercial |
$447.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$171.30
|
| Rate for Payer: Anthem Medicaid |
$158.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,975.00
|
| Rate for Payer: Cash Price |
$3,487.50
|
| Rate for Payer: Cash Price |
$3,487.50
|
| Rate for Payer: Cigna Commercial |
$492.32
|
| Rate for Payer: Healthspan PPO |
$545.20
|
| Rate for Payer: Humana Medicaid |
$158.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$161.59
|
| Rate for Payer: Molina Healthcare Passport |
$158.42
|
| Rate for Payer: Multiplan PHCS |
$4,185.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,882.50
|
| Rate for Payer: UHCCP Medicaid |
$179.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$160.00
|
|
|
INC/DRAINAGE DEEP ABSCESS
|
Facility
|
OP
|
$6,975.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
76100390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$906.75 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$5,370.75
|
| Rate for Payer: Anthem Medicaid |
$2,398.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,440.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,487.50
|
| Rate for Payer: Cash Price |
$3,487.50
|
| Rate for Payer: Cigna Commercial |
$5,789.25
|
| Rate for Payer: First Health Commercial |
$6,626.25
|
| Rate for Payer: Humana Commercial |
$5,928.75
|
| Rate for Payer: Humana KY Medicaid |
$2,398.70
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,423.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,719.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,147.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,446.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,138.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$906.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,162.25
|
| Rate for Payer: PHCS Commercial |
$6,696.00
|
| Rate for Payer: United Healthcare All Payer |
$6,138.00
|
|
|
INC/DRAINAGE DEEP ABSCESS
|
Facility
|
IP
|
$6,975.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
76100390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$906.75 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$5,370.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,440.50
|
| Rate for Payer: Cash Price |
$3,487.50
|
| Rate for Payer: Cigna Commercial |
$5,789.25
|
| Rate for Payer: First Health Commercial |
$6,626.25
|
| Rate for Payer: Humana Commercial |
$5,928.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,719.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,147.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,092.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,138.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$906.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,162.25
|
| Rate for Payer: PHCS Commercial |
$6,696.00
|
| Rate for Payer: United Healthcare All Payer |
$6,138.00
|
|
|
INC/DRAINAGE DEEP ABSCESS(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
761P0390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.42 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$447.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$171.30
|
| Rate for Payer: Anthem Medicaid |
$158.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$492.32
|
| Rate for Payer: Healthspan PPO |
$545.20
|
| Rate for Payer: Humana Medicaid |
$158.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$161.59
|
| Rate for Payer: Molina Healthcare Passport |
$158.42
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$179.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$160.00
|
|
|
INC/DRAINAGE DEEP ABSCESS(T
|
Facility
|
IP
|
$6,375.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
761T0390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$828.75 |
| Max. Negotiated Rate |
$6,120.00 |
| Rate for Payer: Aetna Commercial |
$4,908.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,972.50
|
| Rate for Payer: Cash Price |
$3,187.50
|
| Rate for Payer: Cigna Commercial |
$5,291.25
|
| Rate for Payer: First Health Commercial |
$6,056.25
|
| Rate for Payer: Humana Commercial |
$5,418.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,227.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,704.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,912.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,610.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,781.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,976.25
|
| Rate for Payer: PHCS Commercial |
$6,120.00
|
| Rate for Payer: United Healthcare All Payer |
$5,610.00
|
|
|
INC/DRAINAGE DEEP ABSCESS(T
|
Facility
|
OP
|
$6,375.00
|
|
|
Service Code
|
HCPCS 21501
|
| Hospital Charge Code |
761T0390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$828.75 |
| Max. Negotiated Rate |
$6,120.00 |
| Rate for Payer: Aetna Commercial |
$4,908.75
|
| Rate for Payer: Anthem Medicaid |
$2,192.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,972.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,187.50
|
| Rate for Payer: Cash Price |
$3,187.50
|
| Rate for Payer: Cigna Commercial |
$5,291.25
|
| Rate for Payer: First Health Commercial |
$6,056.25
|
| Rate for Payer: Humana Commercial |
$5,418.75
|
| Rate for Payer: Humana KY Medicaid |
$2,192.36
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,214.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,227.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,704.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,236.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,610.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,781.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,976.25
|
| Rate for Payer: PHCS Commercial |
$6,120.00
|
| Rate for Payer: United Healthcare All Payer |
$5,610.00
|
|
