|
LATUDA 80MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030830
|
| Hospital Charge Code |
25000848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LAVH W/BSO
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
LAVH W/BSO
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,031.70 |
| Max. Negotiated Rate |
$7,547.16 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,390.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,547.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,277.62
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$5,390.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,469.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
LAVH W/BSO
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$649.94 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,341.68
|
| Rate for Payer: Ambetter Exchange |
$837.18
|
| Rate for Payer: Anthem Medicaid |
$649.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$837.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$837.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,004.62
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,312.65
|
| Rate for Payer: Healthspan PPO |
$1,299.09
|
| Rate for Payer: Humana Medicaid |
$649.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$837.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$837.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$662.94
|
| Rate for Payer: Molina Healthcare Passport |
$649.94
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,088.33
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$656.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$837.18
|
|
|
LAVH W/BSO(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
761P2230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$649.94 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,341.68
|
| Rate for Payer: Ambetter Exchange |
$837.18
|
| Rate for Payer: Anthem Medicaid |
$649.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$837.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$837.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,004.62
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,312.65
|
| Rate for Payer: Healthspan PPO |
$1,299.09
|
| Rate for Payer: Humana Medicaid |
$649.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$837.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$837.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$662.94
|
| Rate for Payer: Molina Healthcare Passport |
$649.94
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,088.33
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$656.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$837.18
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
IP
|
$863.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$828.48 |
| Rate for Payer: Aetna Commercial |
$664.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.14
|
| Rate for Payer: Cash Price |
$431.50
|
| Rate for Payer: Cigna Commercial |
$716.29
|
| Rate for Payer: First Health Commercial |
$819.85
|
| Rate for Payer: Humana Commercial |
$733.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$759.44
|
| Rate for Payer: Ohio Health Group HMO |
$647.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.47
|
| Rate for Payer: PHCS Commercial |
$828.48
|
| Rate for Payer: United Healthcare All Payer |
$759.44
|
|
|
LAYER CLOSURE NK - HD - FT
|
Professional
|
Both
|
$863.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.80 |
| Max. Negotiated Rate |
$517.80 |
| Rate for Payer: Aetna Commercial |
$278.49
|
| Rate for Payer: Ambetter Exchange |
$183.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.80
|
| Rate for Payer: Anthem Medicaid |
$113.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$183.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$183.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$220.19
|
| Rate for Payer: Cash Price |
$431.50
|
| Rate for Payer: Cash Price |
$431.50
|
| Rate for Payer: Cigna Commercial |
$352.91
|
| Rate for Payer: Healthspan PPO |
$315.97
|
| Rate for Payer: Humana Medicaid |
$113.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$183.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.49
|
| Rate for Payer: Molina Healthcare Passport |
$113.23
|
| Rate for Payer: Multiplan PHCS |
$517.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$238.54
|
| Rate for Payer: UHCCP Medicaid |
$103.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$183.49
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
IP
|
$493.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
45000062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$473.28 |
| Rate for Payer: Aetna Commercial |
$379.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$384.54
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cigna Commercial |
$409.19
|
| Rate for Payer: First Health Commercial |
$468.35
|
| Rate for Payer: Humana Commercial |
$419.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$404.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$433.84
|
| Rate for Payer: Ohio Health Group HMO |
$369.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.17
|
| Rate for Payer: PHCS Commercial |
$473.28
|
| Rate for Payer: United Healthcare All Payer |
$433.84
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
OP
|
$493.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
45000062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$169.54 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$379.61
|
| Rate for Payer: Anthem Medicaid |
$169.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$384.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cigna Commercial |
$409.19
|
| Rate for Payer: First Health Commercial |
$468.35
|
| Rate for Payer: Humana Commercial |
$419.05
|
| Rate for Payer: Humana KY Medicaid |
$169.54
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$171.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$404.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$433.84
|
| Rate for Payer: Ohio Health Group HMO |
$369.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.17
|
| Rate for Payer: PHCS Commercial |
$473.28
|
| Rate for Payer: United Healthcare All Payer |
$433.84
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
OP
|
$863.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$296.79 |
| Max. Negotiated Rate |
$828.48 |
| Rate for Payer: Aetna Commercial |
$664.51
|
| Rate for Payer: Anthem Medicaid |
$296.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$431.50
|
| Rate for Payer: Cash Price |
$431.50
|
| Rate for Payer: Cigna Commercial |
$716.29
|
| Rate for Payer: First Health Commercial |
$819.85
|
| Rate for Payer: Humana Commercial |
$733.55
|
| Rate for Payer: Humana KY Medicaid |
$296.79
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$299.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$759.44
|
| Rate for Payer: Ohio Health Group HMO |
$647.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$595.47
|
| Rate for Payer: PHCS Commercial |
$828.48
|
| Rate for Payer: United Healthcare All Payer |
$759.44
|
|
|
LAYER CLOSURE NK - HD - FT(P
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761P0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.80 |
| Max. Negotiated Rate |
$352.91 |
| Rate for Payer: Aetna Commercial |
$278.49
|
| Rate for Payer: Ambetter Exchange |
$183.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.80
|
| Rate for Payer: Anthem Medicaid |
$113.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$183.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$183.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$220.19
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$352.91
|
| Rate for Payer: Healthspan PPO |
$315.97
|
| Rate for Payer: Humana Medicaid |
$113.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$183.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.49
|
| Rate for Payer: Molina Healthcare Passport |
$113.23
|
| Rate for Payer: Multiplan PHCS |
$222.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$238.54
|
| Rate for Payer: UHCCP Medicaid |
$103.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$183.49
|
|
|
LAYER CLOSURE NK - HD - FT(T
|
Facility
|
OP
|
$493.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761T0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.54 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$379.61
|
| Rate for Payer: Anthem Medicaid |
$169.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$384.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cigna Commercial |
$409.19
|
| Rate for Payer: First Health Commercial |
$468.35
|
| Rate for Payer: Humana Commercial |
$419.05
|
| Rate for Payer: Humana KY Medicaid |
$169.54
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$171.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$404.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$433.84
|
| Rate for Payer: Ohio Health Group HMO |
$369.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.17
|
| Rate for Payer: PHCS Commercial |
$473.28
|
| Rate for Payer: United Healthcare All Payer |
$433.84
|
|
|
LAYER CLOSURE NK - HD - FT(T
|
Facility
|
IP
|
$493.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761T0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$473.28 |
| Rate for Payer: Aetna Commercial |
$379.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$384.54
|
| Rate for Payer: Cash Price |
$246.50
|
| Rate for Payer: Cigna Commercial |
$409.19
|
| Rate for Payer: First Health Commercial |
$468.35
|
| Rate for Payer: Humana Commercial |
$419.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$404.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$433.84
|
| Rate for Payer: Ohio Health Group HMO |
$369.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$394.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$340.17
|
| Rate for Payer: PHCS Commercial |
$473.28
|
| Rate for Payer: United Healthcare All Payer |
$433.84
|
|
|
LAYER CLOSURE OF WOUND
|
Professional
|
Both
|
$931.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.32 |
| Max. Negotiated Rate |
$558.60 |
| Rate for Payer: Aetna Commercial |
$305.77
|
| Rate for Payer: Ambetter Exchange |
$201.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.32
|
| Rate for Payer: Anthem Medicaid |
$141.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$201.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$201.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.29
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$272.16
|
| Rate for Payer: Healthspan PPO |
$363.89
|
| Rate for Payer: Humana Medicaid |
$141.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$201.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.25
|
| Rate for Payer: Molina Healthcare Passport |
$141.42
|
| Rate for Payer: Multiplan PHCS |
$558.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.48
|
| Rate for Payer: UHCCP Medicaid |
$113.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$201.91
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
45000067
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$931.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$279.30 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$931.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$320.17 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem Medicaid |
$320.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Humana KY Medicaid |
$320.17
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$323.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$744.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$809.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$642.39
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
45000067
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUND(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
761P0145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.32 |
| Max. Negotiated Rate |
$363.89 |
| Rate for Payer: Aetna Commercial |
$305.77
|
| Rate for Payer: Ambetter Exchange |
$201.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.32
|
| Rate for Payer: Anthem Medicaid |
$141.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$201.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$201.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$242.29
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$272.16
|
| Rate for Payer: Healthspan PPO |
$363.89
|
| Rate for Payer: Humana Medicaid |
$141.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$201.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.25
|
| Rate for Payer: Molina Healthcare Passport |
$141.42
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.48
|
| Rate for Payer: UHCCP Medicaid |
$113.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$201.91
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
761T0135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
45000059
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
45000056
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
761P0135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.52 |
| Max. Negotiated Rate |
$379.66 |
| Rate for Payer: Aetna Commercial |
$272.89
|
| Rate for Payer: Ambetter Exchange |
$177.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.52
|
| Rate for Payer: Anthem Medicaid |
$101.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$177.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$177.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.41
|
| Rate for Payer: Cash Price |
$194.50
|
| Rate for Payer: Cash Price |
$194.50
|
| Rate for Payer: Cigna Commercial |
$379.66
|
| Rate for Payer: Healthspan PPO |
$331.61
|
| Rate for Payer: Humana Medicaid |
$101.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$241.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$177.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.63
|
| Rate for Payer: Molina Healthcare Passport |
$101.60
|
| Rate for Payer: Multiplan PHCS |
$233.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.19
|
| Rate for Payer: UHCCP Medicaid |
$100.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$177.84
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
45000056
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
IP
|
$920.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
76100135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.00 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$800.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$634.80
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
