|
LASER SURG PENIS LESION(S)(T
|
Facility
|
OP
|
$4,571.00
|
|
|
Service Code
|
HCPCS 54057
|
| Hospital Charge Code |
761T2126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,571.97 |
| Max. Negotiated Rate |
$4,388.16 |
| Rate for Payer: Aetna Commercial |
$3,519.67
|
| Rate for Payer: Anthem Medicaid |
$1,571.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,565.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cigna Commercial |
$3,793.93
|
| Rate for Payer: First Health Commercial |
$4,342.45
|
| Rate for Payer: Humana Commercial |
$3,885.35
|
| Rate for Payer: Humana KY Medicaid |
$1,571.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,587.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,748.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,373.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,603.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,022.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,976.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,153.99
|
| Rate for Payer: PHCS Commercial |
$4,388.16
|
| Rate for Payer: United Healthcare All Payer |
$4,022.48
|
|
|
LASER SURG PENIS LESION(S)(T
|
Facility
|
IP
|
$4,571.00
|
|
|
Service Code
|
HCPCS 54057
|
| Hospital Charge Code |
761T2126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,371.30 |
| Max. Negotiated Rate |
$4,388.16 |
| Rate for Payer: Aetna Commercial |
$3,519.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,565.38
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cigna Commercial |
$3,793.93
|
| Rate for Payer: First Health Commercial |
$4,342.45
|
| Rate for Payer: Humana Commercial |
$3,885.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,748.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,373.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,022.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,976.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,153.99
|
| Rate for Payer: PHCS Commercial |
$4,388.16
|
| Rate for Payer: United Healthcare All Payer |
$4,022.48
|
|
|
LASER VAP CERVIX
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
LASER VAP CERVIX
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.12 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
LASER VAP CERVIX
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.52 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$198.39
|
| Rate for Payer: Ambetter Exchange |
$137.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.52
|
| Rate for Payer: Anthem Medicaid |
$133.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.95
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$195.69
|
| Rate for Payer: Healthspan PPO |
$207.13
|
| Rate for Payer: Humana Medicaid |
$133.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$170.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.55
|
| Rate for Payer: Molina Healthcare Passport |
$133.87
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.70
|
| Rate for Payer: UHCCP Medicaid |
$109.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.21
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.46
|
|
|
LASER VAP CERVIX(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
761P2202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.52 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$198.39
|
| Rate for Payer: Ambetter Exchange |
$137.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.52
|
| Rate for Payer: Anthem Medicaid |
$133.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.95
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$195.69
|
| Rate for Payer: Healthspan PPO |
$207.13
|
| Rate for Payer: Humana Medicaid |
$133.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$170.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.55
|
| Rate for Payer: Molina Healthcare Passport |
$133.87
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.70
|
| Rate for Payer: UHCCP Medicaid |
$109.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.21
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.46
|
|
|
LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)
|
Facility
|
OP
|
$6,576.02
|
|
|
Service Code
|
CPT 52648
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,697.16 |
| Max. Negotiated Rate |
$6,576.02 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,697.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,576.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,341.17
|
| Rate for Payer: Humana Medicare Advantage |
$4,697.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,636.59
|
|
|
LASIX 20 MG (40MG/5ML SOL)
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 54329863
|
| Hospital Charge Code |
25000844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
LASIX 20 MG (40MG/5ML SOL)
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 54329863
|
| Hospital Charge Code |
25000844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
LASIX (FUROSEMIDE) 2 20MG/1TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904717761
|
| Hospital Charge Code |
25000841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
LASIX (FUROSEMIDE) 2 20MG/1TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904717761
|
| Hospital Charge Code |
25000841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
LASIX (FUROSEMIDE) 4 40MG/1TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 904717861
|
| Hospital Charge Code |
25000842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
LASIX (FUROSEMIDE) 4 40MG/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 904717861
|
| Hospital Charge Code |
25000842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
LASIX (FUROSEMIDE) 8 80MG/1TAB
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 51079052720
|
| Hospital Charge Code |
25000843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
LASIX (FUROSEMIDE) 8 80MG/1TAB
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 51079052720
|
| Hospital Charge Code |
25000843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
OP
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,745.64 |
| Max. Negotiated Rate |
$4,872.96 |
| Rate for Payer: Aetna Commercial |
$3,908.52
|
| Rate for Payer: Anthem Medicaid |
$1,745.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$4,213.08
|
| Rate for Payer: First Health Commercial |
$4,822.20
|
| Rate for Payer: Humana Commercial |
$4,314.60
|
| Rate for Payer: Humana KY Medicaid |
$1,745.64
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,763.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,780.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,466.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,416.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,502.44
|
| Rate for Payer: PHCS Commercial |
$4,872.96
|
| Rate for Payer: United Healthcare All Payer |
$4,466.88
|
|
|
LATERAL CANTHOPEXY
|
Professional
|
Both
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.09 |
| Max. Negotiated Rate |
$3,045.60 |
| Rate for Payer: Aetna Commercial |
$487.53
|
| Rate for Payer: Ambetter Exchange |
$371.24
|
| Rate for Payer: Anthem Medicaid |
$236.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$371.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$371.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.49
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$540.36
|
| Rate for Payer: Healthspan PPO |
$441.60
|
| Rate for Payer: Humana Medicaid |
$236.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$371.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$371.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.81
|
| Rate for Payer: Molina Healthcare Passport |
$236.09
|
| Rate for Payer: Multiplan PHCS |
$3,045.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$482.61
|
| Rate for Payer: UHCCP Medicaid |
$1,776.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$371.24
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
IP
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,522.80 |
| Max. Negotiated Rate |
$4,872.96 |
| Rate for Payer: Aetna Commercial |
$3,908.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.28
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$4,213.08
|
| Rate for Payer: First Health Commercial |
$4,822.20
|
| Rate for Payer: Humana Commercial |
$4,314.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,522.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,466.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,416.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,502.44
|
| Rate for Payer: PHCS Commercial |
$4,872.96
|
| Rate for Payer: United Healthcare All Payer |
$4,466.88
|
|
|
LATERAL CANTHOPEXY(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761P0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$540.36 |
| Rate for Payer: Aetna Commercial |
$487.53
|
| Rate for Payer: Ambetter Exchange |
$371.24
|
| Rate for Payer: Anthem Medicaid |
$236.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$371.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$371.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.49
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$540.36
|
| Rate for Payer: Healthspan PPO |
$441.60
|
| Rate for Payer: Humana Medicaid |
$236.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$371.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$371.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.81
|
| Rate for Payer: Molina Healthcare Passport |
$236.09
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$482.61
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$371.24
|
|
|
LATERAL CANTHOPEXY(T
|
Facility
|
IP
|
$4,476.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761T0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,342.80 |
| Max. Negotiated Rate |
$4,296.96 |
| Rate for Payer: Aetna Commercial |
$3,446.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,491.28
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,715.08
|
| Rate for Payer: First Health Commercial |
$4,252.20
|
| Rate for Payer: Humana Commercial |
$3,804.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,670.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,303.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,580.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,894.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,088.44
|
| Rate for Payer: PHCS Commercial |
$4,296.96
|
| Rate for Payer: United Healthcare All Payer |
$3,938.88
|
|
|
LATERAL CANTHOPEXY(T
|
Facility
|
OP
|
$4,476.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761T0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,539.30 |
| Max. Negotiated Rate |
$4,296.96 |
| Rate for Payer: Aetna Commercial |
$3,446.52
|
| Rate for Payer: Anthem Medicaid |
$1,539.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,491.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,715.08
|
| Rate for Payer: First Health Commercial |
$4,252.20
|
| Rate for Payer: Humana Commercial |
$3,804.60
|
| Rate for Payer: Humana KY Medicaid |
$1,539.30
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,554.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,670.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,303.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,570.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,580.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,894.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,088.44
|
| Rate for Payer: PHCS Commercial |
$4,296.96
|
| Rate for Payer: United Healthcare All Payer |
$3,938.88
|
|
|
LATERALIZD HUM CUP DIA 36+ 3MM
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 3MM
|
Facility
|
IP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 6MM
|
Facility
|
IP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 6MM
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
