|
LENS ZCB00 DIOPTER +7.5 (S)
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +7.5 (S)
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +8.0 (S)
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +8.0 (S)
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +8.5 (S)
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +8.5 (S)
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +9.0 (S)
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +9.0 (S)
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +9.5 (S)
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LENS ZCB00 DIOPTER +9.5 (S)
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
LEQVIO 1MG (284MG PFS)
|
Facility
|
OP
|
$18,614.91
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
25004189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$17,870.31 |
| Rate for Payer: Aetna Commercial |
$14,333.48
|
| Rate for Payer: Anthem Medicaid |
$6,401.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,519.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.38
|
| Rate for Payer: Cash Price |
$9,307.46
|
| Rate for Payer: Cash Price |
$9,307.46
|
| Rate for Payer: Cigna Commercial |
$15,450.38
|
| Rate for Payer: First Health Commercial |
$17,684.16
|
| Rate for Payer: Humana Commercial |
$15,822.67
|
| Rate for Payer: Humana KY Medicaid |
$6,401.67
|
| Rate for Payer: Humana Medicare Advantage |
$12.13
|
| Rate for Payer: Kentucky WC Medicaid |
$6,466.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,264.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,737.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,530.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,381.12
|
| Rate for Payer: Ohio Health Group HMO |
$13,961.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,722.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,419.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,770.62
|
| Rate for Payer: PHCS Commercial |
$17,870.31
|
| Rate for Payer: United Healthcare All Payer |
$16,381.12
|
|
|
LEQVIO 1MG (284MG PFS)
|
Facility
|
IP
|
$18,614.91
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
25004189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,419.94 |
| Max. Negotiated Rate |
$17,870.31 |
| Rate for Payer: Aetna Commercial |
$14,333.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,519.63
|
| Rate for Payer: Cash Price |
$9,307.46
|
| Rate for Payer: Cigna Commercial |
$15,450.38
|
| Rate for Payer: First Health Commercial |
$17,684.16
|
| Rate for Payer: Humana Commercial |
$15,822.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,264.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,737.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,584.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,381.12
|
| Rate for Payer: Ohio Health Group HMO |
$13,961.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,722.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,419.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,770.62
|
| Rate for Payer: PHCS Commercial |
$17,870.31
|
| Rate for Payer: United Healthcare All Payer |
$16,381.12
|
|
|
LESION EXC OF TENDON SHEATH
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.98 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$449.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.82
|
| Rate for Payer: Anthem Medicaid |
$159.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$493.30
|
| Rate for Payer: Healthspan PPO |
$687.13
|
| Rate for Payer: Humana Medicaid |
$159.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$399.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.18
|
| Rate for Payer: Molina Healthcare Passport |
$159.98
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$170.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.58
|
|
|
LESION EXC OF TENDON SHEATH
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$1,945.78 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,389.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,945.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,876.28
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,389.84
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,667.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
LESION EXC OF TENDON SHEATH
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
76100678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
LESION EXC OF TENDON SHEATH(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 26160
|
| Hospital Charge Code |
761P0678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.98 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$449.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.82
|
| Rate for Payer: Anthem Medicaid |
$159.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$493.30
|
| Rate for Payer: Healthspan PPO |
$687.13
|
| Rate for Payer: Humana Medicaid |
$159.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$399.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.18
|
| Rate for Payer: Molina Healthcare Passport |
$159.98
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$170.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.58
|
|
|
LET ME CLARIFY
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200127
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
LETS TOPICAL GEL 3ML SYRINGE
|
Facility
|
OP
|
$10.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.47 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cigna Commercial |
$9.06
|
| Rate for Payer: First Health Commercial |
$10.36
|
| Rate for Payer: Humana Commercial |
$9.27
|
| Rate for Payer: Humana KY Medicaid |
$3.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.60
|
| Rate for Payer: Ohio Health Group HMO |
$8.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$10.47
|
| Rate for Payer: United Healthcare All Payer |
$9.60
|
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Anthem Medicaid |
$3.75
|
|
|
LETS TOPICAL GEL 3ML SYRINGE
|
Facility
|
IP
|
$10.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.47 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: Cigna Commercial |
$9.06
|
| Rate for Payer: First Health Commercial |
$10.36
|
| Rate for Payer: Humana Commercial |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.60
|
| Rate for Payer: Ohio Health Group HMO |
$8.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.38
|
| Rate for Payer: PHCS Commercial |
$10.47
|
| Rate for Payer: United Healthcare All Payer |
$9.60
|
|
|
LEUCOVORIN 50mg (500mg SDV)
|
Facility
|
IP
|
$545.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25004393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
LEUCOVORIN 50mg (500mg SDV)
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25004393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem Medicaid |
$187.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Humana KY Medicaid |
$187.43
|
| Rate for Payer: Kentucky WC Medicaid |
$189.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
LEUCOVORIN 50MG/5ML(100MG/10ML
|
Facility
|
OP
|
$87.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$83.71 |
| Rate for Payer: Anthem Medicaid |
$29.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.02
|
| Rate for Payer: Cash Price |
$43.60
|
| Rate for Payer: Cigna Commercial |
$72.38
|
| Rate for Payer: First Health Commercial |
$82.84
|
| Rate for Payer: Humana Commercial |
$74.12
|
| Rate for Payer: Humana KY Medicaid |
$29.99
|
| Rate for Payer: Kentucky WC Medicaid |
$30.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.74
|
| Rate for Payer: Ohio Health Group HMO |
$65.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.03
|
| Rate for Payer: PHCS Commercial |
$83.71
|
| Rate for Payer: United Healthcare All Payer |
$76.74
|
| Rate for Payer: Aetna Commercial |
$67.14
|
|
|
LEUCOVORIN 50MG/5ML(100MG/10ML
|
Facility
|
IP
|
$87.20
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$83.71 |
| Rate for Payer: Aetna Commercial |
$67.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.02
|
| Rate for Payer: Cash Price |
$43.60
|
| Rate for Payer: Cigna Commercial |
$72.38
|
| Rate for Payer: First Health Commercial |
$82.84
|
| Rate for Payer: Humana Commercial |
$74.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.74
|
| Rate for Payer: Ohio Health Group HMO |
$65.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.03
|
| Rate for Payer: PHCS Commercial |
$83.71
|
| Rate for Payer: United Healthcare All Payer |
$76.74
|
|
|
LEUCOVORIN CALC 50MG350MG VL
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.07 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.09
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
LEUCOVORIN CALC 50MG350MG VL
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
25001919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.07 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem Medicaid |
$116.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Humana KY Medicaid |
$116.58
|
| Rate for Payer: Kentucky WC Medicaid |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.09
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
