|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
761T0146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
45000068
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYER CLOSURE WOUND(P
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761P0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$630.00 |
| Rate for Payer: Aetna Commercial |
$341.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.68
|
| Rate for Payer: Anthem Medicaid |
$156.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$630.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$322.55
|
| Rate for Payer: Healthspan PPO |
$405.24
|
| Rate for Payer: Humana Medicaid |
$156.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.40
|
| Rate for Payer: Molina Healthcare Passport |
$156.27
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$441.00
|
| Rate for Payer: UHCCP Medicaid |
$128.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.83
|
|
|
LAYER CLOSURE WOUND(T
|
Facility
|
OP
|
$1,245.80
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761T0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$161.95 |
| Max. Negotiated Rate |
$1,195.97 |
| Rate for Payer: Aetna Commercial |
$959.27
|
| Rate for Payer: Anthem Medicaid |
$428.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$622.90
|
| Rate for Payer: Cash Price |
$622.90
|
| Rate for Payer: Cigna Commercial |
$1,034.01
|
| Rate for Payer: First Health Commercial |
$1,183.51
|
| Rate for Payer: Humana Commercial |
$1,058.93
|
| Rate for Payer: Humana KY Medicaid |
$428.43
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$432.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$437.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,096.30
|
| Rate for Payer: Ohio Health Group HMO |
$934.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.20
|
| Rate for Payer: PHCS Commercial |
$1,195.97
|
| Rate for Payer: United Healthcare All Payer |
$1,096.30
|
|
|
LAYER CLOSURE WOUND(T
|
Facility
|
IP
|
$1,245.80
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761T0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$161.95 |
| Max. Negotiated Rate |
$1,195.97 |
| Rate for Payer: Aetna Commercial |
$959.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.72
|
| Rate for Payer: Cash Price |
$622.90
|
| Rate for Payer: Cigna Commercial |
$1,034.01
|
| Rate for Payer: First Health Commercial |
$1,183.51
|
| Rate for Payer: Humana Commercial |
$1,058.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,096.30
|
| Rate for Payer: Ohio Health Group HMO |
$934.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.20
|
| Rate for Payer: PHCS Commercial |
$1,195.97
|
| Rate for Payer: United Healthcare All Payer |
$1,096.30
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761T0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$803.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.39 |
| Max. Negotiated Rate |
$770.88 |
| Rate for Payer: Aetna Commercial |
$618.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.34
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cigna Commercial |
$666.49
|
| Rate for Payer: First Health Commercial |
$762.85
|
| Rate for Payer: Humana Commercial |
$682.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.64
|
| Rate for Payer: Ohio Health Group HMO |
$602.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.93
|
| Rate for Payer: PHCS Commercial |
$770.88
|
| Rate for Payer: United Healthcare All Payer |
$706.64
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Professional
|
Both
|
$803.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.98 |
| Max. Negotiated Rate |
$803.00 |
| Rate for Payer: Aetna Commercial |
$223.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.86
|
| Rate for Payer: Anthem Medicaid |
$72.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$803.00
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cigna Commercial |
$302.40
|
| Rate for Payer: Healthspan PPO |
$259.20
|
| Rate for Payer: Humana Medicaid |
$72.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.44
|
| Rate for Payer: Molina Healthcare Passport |
$72.98
|
| Rate for Payer: Multiplan PHCS |
$481.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$562.10
|
| Rate for Payer: UHCCP Medicaid |
$94.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.71
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
45000055
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
45000055
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761T0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$803.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.39 |
| Max. Negotiated Rate |
$770.88 |
| Rate for Payer: Aetna Commercial |
$618.31
|
| Rate for Payer: Anthem Medicaid |
$276.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cigna Commercial |
$666.49
|
| Rate for Payer: First Health Commercial |
$762.85
|
| Rate for Payer: Humana Commercial |
$682.55
|
| Rate for Payer: Humana KY Medicaid |
$276.15
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$278.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.64
|
| Rate for Payer: Ohio Health Group HMO |
$602.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.93
|
| Rate for Payer: PHCS Commercial |
$770.88
|
| Rate for Payer: United Healthcare All Payer |
$706.64
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761P0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.98 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$223.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.86
|
| Rate for Payer: Anthem Medicaid |
$72.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$304.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$302.40
|
| Rate for Payer: Healthspan PPO |
$259.20
|
| Rate for Payer: Humana Medicaid |
$72.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.44
|
| Rate for Payer: Molina Healthcare Passport |
$72.98
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.80
|
| Rate for Payer: UHCCP Medicaid |
$94.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.71
|
|
|
LAYRNGOSCOPY
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
41000020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$252.24 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Aetna Commercial |
$324.20
|
| Rate for Payer: Anthem Medicaid |
$252.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$328.50
|
| Rate for Payer: Healthspan PPO |
$273.40
|
| Rate for Payer: Humana Medicaid |
$252.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.28
|
| Rate for Payer: Molina Healthcare Passport |
$252.24
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$254.76
|
|
|
LAYRNGOSCOPY(P
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
410P0020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$252.24 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Aetna Commercial |
$324.20
|
| Rate for Payer: Anthem Medicaid |
$252.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$328.50
|
| Rate for Payer: Healthspan PPO |
$273.40
|
| Rate for Payer: Humana Medicaid |
$252.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.28
|
| Rate for Payer: Molina Healthcare Passport |
$252.24
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$254.76
|
|
|
L-CARNITINE 500MG TABLET
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 30768003741
|
| Hospital Charge Code |
25000849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
L-CARNITINE 500MG TABLET
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 30768003741
|
| Hospital Charge Code |
25000849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
LCB 6FR 90CM
|
Facility
|
IP
|
$1,068.96
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.96 |
| Max. Negotiated Rate |
$1,026.20 |
| Rate for Payer: Aetna Commercial |
$823.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$833.79
|
| Rate for Payer: Cash Price |
$534.48
|
| Rate for Payer: Cigna Commercial |
$887.24
|
| Rate for Payer: First Health Commercial |
$1,015.51
|
| Rate for Payer: Humana Commercial |
$908.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$876.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$788.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$320.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$940.68
|
| Rate for Payer: Ohio Health Group HMO |
$801.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$331.38
|
| Rate for Payer: PHCS Commercial |
$1,026.20
|
| Rate for Payer: United Healthcare All Payer |
$940.68
|
|
|
LCB 6FR 90CM
|
Facility
|
OP
|
$1,068.96
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$138.96 |
| Max. Negotiated Rate |
$1,026.20 |
| Rate for Payer: Aetna Commercial |
$823.10
|
| Rate for Payer: Anthem Medicaid |
$367.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$833.79
|
| Rate for Payer: Cash Price |
$534.48
|
| Rate for Payer: Cigna Commercial |
$887.24
|
| Rate for Payer: First Health Commercial |
$1,015.51
|
| Rate for Payer: Humana Commercial |
$908.62
|
| Rate for Payer: Humana KY Medicaid |
$367.62
|
| Rate for Payer: Kentucky WC Medicaid |
$371.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$876.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$788.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$320.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$374.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$940.68
|
| Rate for Payer: Ohio Health Group HMO |
$801.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$331.38
|
| Rate for Payer: PHCS Commercial |
$1,026.20
|
| Rate for Payer: United Healthcare All Payer |
$940.68
|
|
|
LCB CATH 5F DIAG.
|
Facility
|
IP
|
$162.56
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Aetna Commercial |
$125.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.80
|
| Rate for Payer: Cash Price |
$81.28
|
| Rate for Payer: Cigna Commercial |
$134.92
|
| Rate for Payer: First Health Commercial |
$154.43
|
| Rate for Payer: Humana Commercial |
$138.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$119.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.05
|
| Rate for Payer: Ohio Health Group HMO |
$121.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.39
|
| Rate for Payer: PHCS Commercial |
$156.06
|
| Rate for Payer: United Healthcare All Payer |
$143.05
|
|
|
LCB CATH 5F DIAG.
|
Facility
|
OP
|
$162.56
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$156.06 |
| Rate for Payer: Aetna Commercial |
$125.17
|
| Rate for Payer: Anthem Medicaid |
$55.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.80
|
| Rate for Payer: Cash Price |
$81.28
|
| Rate for Payer: Cigna Commercial |
$134.92
|
| Rate for Payer: First Health Commercial |
$154.43
|
| Rate for Payer: Humana Commercial |
$138.18
|
| Rate for Payer: Humana KY Medicaid |
$55.90
|
| Rate for Payer: Kentucky WC Medicaid |
$56.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$119.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.05
|
| Rate for Payer: Ohio Health Group HMO |
$121.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.39
|
| Rate for Payer: PHCS Commercial |
$156.06
|
| Rate for Payer: United Healthcare All Payer |
$143.05
|
|
|
LCCK 0D SZ3 5MM 31*31 CPL
|
Facility
|
OP
|
$26,426.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,435.48 |
| Max. Negotiated Rate |
$25,369.73 |
| Rate for Payer: Aetna Commercial |
$20,348.64
|
| Rate for Payer: Anthem Medicaid |
$9,088.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,612.90
|
| Rate for Payer: Cash Price |
$13,213.40
|
| Rate for Payer: Cigna Commercial |
$21,934.24
|
| Rate for Payer: First Health Commercial |
$25,105.46
|
| Rate for Payer: Humana Commercial |
$22,462.78
|
| Rate for Payer: Humana KY Medicaid |
$9,088.18
|
| Rate for Payer: Kentucky WC Medicaid |
$9,180.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,669.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,502.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,928.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,270.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,255.58
|
| Rate for Payer: Ohio Health Group HMO |
$19,820.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,285.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,435.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,192.31
|
| Rate for Payer: PHCS Commercial |
$25,369.73
|
| Rate for Payer: United Healthcare All Payer |
$23,255.58
|
|
|
LCCK 0D SZ3 5MM 31*31 CPL
|
Facility
|
IP
|
$26,426.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,435.48 |
| Max. Negotiated Rate |
$25,369.73 |
| Rate for Payer: Aetna Commercial |
$20,348.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,612.90
|
| Rate for Payer: Cash Price |
$13,213.40
|
| Rate for Payer: Cigna Commercial |
$21,934.24
|
| Rate for Payer: First Health Commercial |
$25,105.46
|
| Rate for Payer: Humana Commercial |
$22,462.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,669.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,502.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,928.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,255.58
|
| Rate for Payer: Ohio Health Group HMO |
$19,820.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,285.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,435.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,192.31
|
| Rate for Payer: PHCS Commercial |
$25,369.73
|
| Rate for Payer: United Healthcare All Payer |
$23,255.58
|
|
|
LCCK 0D SZ3 5MM 36*31 CPL
|
Facility
|
OP
|
$26,426.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,435.48 |
| Max. Negotiated Rate |
$25,369.73 |
| Rate for Payer: Aetna Commercial |
$20,348.64
|
| Rate for Payer: Anthem Medicaid |
$9,088.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,612.90
|
| Rate for Payer: Cash Price |
$13,213.40
|
| Rate for Payer: Cigna Commercial |
$21,934.24
|
| Rate for Payer: First Health Commercial |
$25,105.46
|
| Rate for Payer: Humana Commercial |
$22,462.78
|
| Rate for Payer: Humana KY Medicaid |
$9,088.18
|
| Rate for Payer: Kentucky WC Medicaid |
$9,180.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,669.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,502.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,928.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,270.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,255.58
|
| Rate for Payer: Ohio Health Group HMO |
$19,820.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,285.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,435.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,192.31
|
| Rate for Payer: PHCS Commercial |
$25,369.73
|
| Rate for Payer: United Healthcare All Payer |
$23,255.58
|
|
|
LCCK 0D SZ3 5MM 36*31 CPL
|
Facility
|
IP
|
$26,426.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,435.48 |
| Max. Negotiated Rate |
$25,369.73 |
| Rate for Payer: Aetna Commercial |
$20,348.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,612.90
|
| Rate for Payer: Cash Price |
$13,213.40
|
| Rate for Payer: Cigna Commercial |
$21,934.24
|
| Rate for Payer: First Health Commercial |
$25,105.46
|
| Rate for Payer: Humana Commercial |
$22,462.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,669.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,502.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,928.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,255.58
|
| Rate for Payer: Ohio Health Group HMO |
$19,820.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,285.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,435.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,192.31
|
| Rate for Payer: PHCS Commercial |
$25,369.73
|
| Rate for Payer: United Healthcare All Payer |
$23,255.58
|
|
