|
MOD SED OTH PHYS/QHP 5/>YRS(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
370P0177
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$61.64 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Ambetter Exchange |
$70.21
|
| Rate for Payer: Anthem Medicaid |
$61.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$70.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$70.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$84.25
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$108.76
|
| Rate for Payer: Humana Medicaid |
$61.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$70.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.87
|
| Rate for Payer: Molina Healthcare Passport |
$61.64
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$91.27
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$70.21
|
|
|
MOD SED OTH PHYS/QHP 5/>YRS(T
|
Facility
|
IP
|
$308.78
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
370T0177
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$92.63 |
| Max. Negotiated Rate |
$296.43 |
| Rate for Payer: Aetna Commercial |
$237.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$240.85
|
| Rate for Payer: Cash Price |
$154.39
|
| Rate for Payer: Cigna Commercial |
$256.29
|
| Rate for Payer: First Health Commercial |
$293.34
|
| Rate for Payer: Humana Commercial |
$262.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$253.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$227.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.73
|
| Rate for Payer: Ohio Health Group HMO |
$231.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.06
|
| Rate for Payer: PHCS Commercial |
$296.43
|
| Rate for Payer: United Healthcare All Payer |
$271.73
|
|
|
MOD SED OTH PHYS/QHP 5/>YRS(T
|
Facility
|
OP
|
$308.78
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
370T0177
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$92.63 |
| Max. Negotiated Rate |
$296.43 |
| Rate for Payer: Aetna Commercial |
$237.76
|
| Rate for Payer: Anthem Medicaid |
$106.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$240.85
|
| Rate for Payer: Cash Price |
$154.39
|
| Rate for Payer: Cigna Commercial |
$256.29
|
| Rate for Payer: First Health Commercial |
$293.34
|
| Rate for Payer: Humana Commercial |
$262.46
|
| Rate for Payer: Humana KY Medicaid |
$106.19
|
| Rate for Payer: Kentucky WC Medicaid |
$107.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$253.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$227.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$108.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.73
|
| Rate for Payer: Ohio Health Group HMO |
$231.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.06
|
| Rate for Payer: PHCS Commercial |
$296.43
|
| Rate for Payer: United Healthcare All Payer |
$271.73
|
|
|
MOD SED SAME PHYS/QHP <5 YRS
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS 99151
|
| Hospital Charge Code |
37000274
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$106.17 |
| Rate for Payer: Ambetter Exchange |
$22.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$19.66
|
| Rate for Payer: Anthem Medicaid |
$58.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$22.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$22.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$26.98
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$106.17
|
| Rate for Payer: Humana Medicaid |
$58.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$22.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.57
|
| Rate for Payer: Molina Healthcare Passport |
$58.40
|
| Rate for Payer: Multiplan PHCS |
$37.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$29.22
|
| Rate for Payer: UHCCP Medicaid |
$20.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$22.48
|
|
|
MOD TAP FEM PORUS 11.X142
|
Facility
|
OP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem Medicaid |
$7,914.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Humana KY Medicaid |
$7,914.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7,995.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,073.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
MOD TAP FEM PORUS 11.X142
|
Facility
|
IP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
MOD TP LCK(R) FEM PORS 11X142
|
Facility
|
IP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
MOD TP LCK(R) FEM PORS 11X142
|
Facility
|
OP
|
$23,015.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,904.50 |
| Max. Negotiated Rate |
$22,094.40 |
| Rate for Payer: Aetna Commercial |
$17,721.55
|
| Rate for Payer: Anthem Medicaid |
$7,914.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,951.70
|
| Rate for Payer: Cash Price |
$11,507.50
|
| Rate for Payer: Cigna Commercial |
$19,102.45
|
| Rate for Payer: First Health Commercial |
$21,864.25
|
| Rate for Payer: Humana Commercial |
$19,562.75
|
| Rate for Payer: Humana KY Medicaid |
$7,914.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7,995.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,872.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,985.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,904.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,073.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,253.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,023.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,880.35
|
| Rate for Payer: PHCS Commercial |
$22,094.40
|
| Rate for Payer: United Healthcare All Payer |
$20,253.20
|
|
|
MODULAR HEAD SLEEVE +4MM
|
Facility
|
OP
|
$3,035.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$910.78 |
| Max. Negotiated Rate |
$2,914.50 |
| Rate for Payer: Aetna Commercial |
$2,337.67
|
| Rate for Payer: Anthem Medicaid |
$1,044.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,368.03
|
| Rate for Payer: Cash Price |
$1,517.97
|
| Rate for Payer: Cigna Commercial |
$2,519.83
|
| Rate for Payer: First Health Commercial |
$2,884.14
|
| Rate for Payer: Humana Commercial |
$2,580.55
|
| Rate for Payer: Humana KY Medicaid |
$1,044.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,054.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,489.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,240.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,065.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,671.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,276.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,428.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,094.80
|
| Rate for Payer: PHCS Commercial |
$2,914.50
|
| Rate for Payer: United Healthcare All Payer |
$2,671.63
|
|
|
MODULAR HEAD SLEEVE +4MM
|
Facility
|
IP
|
$3,035.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$910.78 |
| Max. Negotiated Rate |
$2,914.50 |
| Rate for Payer: Aetna Commercial |
$2,337.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,368.03
|
| Rate for Payer: Cash Price |
$1,517.97
|
| Rate for Payer: Cigna Commercial |
$2,519.83
|
| Rate for Payer: First Health Commercial |
$2,884.14
|
| Rate for Payer: Humana Commercial |
$2,580.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,489.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,240.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,671.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,276.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,428.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,094.80
|
| Rate for Payer: PHCS Commercial |
$2,914.50
|
| Rate for Payer: United Healthcare All Payer |
$2,671.63
|
|
|
MODULAR HEAD SLEEVE +8MM
|
Facility
|
IP
|
$3,035.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$910.78 |
| Max. Negotiated Rate |
$2,914.50 |
| Rate for Payer: Aetna Commercial |
$2,337.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,368.03
|
| Rate for Payer: Cash Price |
$1,517.97
|
| Rate for Payer: Cigna Commercial |
$2,519.83
|
| Rate for Payer: First Health Commercial |
$2,884.14
|
| Rate for Payer: Humana Commercial |
$2,580.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,489.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,240.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,671.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,276.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,428.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,094.80
|
| Rate for Payer: PHCS Commercial |
$2,914.50
|
| Rate for Payer: United Healthcare All Payer |
$2,671.63
|
|
|
MODULAR HEAD SLEEVE +8MM
|
Facility
|
OP
|
$3,035.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$910.78 |
| Max. Negotiated Rate |
$2,914.50 |
| Rate for Payer: Aetna Commercial |
$2,337.67
|
| Rate for Payer: Anthem Medicaid |
$1,044.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,368.03
|
| Rate for Payer: Cash Price |
$1,517.97
|
| Rate for Payer: Cigna Commercial |
$2,519.83
|
| Rate for Payer: First Health Commercial |
$2,884.14
|
| Rate for Payer: Humana Commercial |
$2,580.55
|
| Rate for Payer: Humana KY Medicaid |
$1,044.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,054.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,489.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,240.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$910.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,065.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,671.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,276.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,428.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,641.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,094.80
|
| Rate for Payer: PHCS Commercial |
$2,914.50
|
| Rate for Payer: United Healthcare All Payer |
$2,671.63
|
|
|
MODULAR II-C HUMERAL STEM
|
Facility
|
OP
|
$11,757.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,527.25 |
| Max. Negotiated Rate |
$11,287.20 |
| Rate for Payer: Aetna Commercial |
$9,053.27
|
| Rate for Payer: Anthem Medicaid |
$4,043.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,170.85
|
| Rate for Payer: Cash Price |
$5,878.75
|
| Rate for Payer: Cigna Commercial |
$9,758.73
|
| Rate for Payer: First Health Commercial |
$11,169.62
|
| Rate for Payer: Humana Commercial |
$9,993.88
|
| Rate for Payer: Humana KY Medicaid |
$4,043.40
|
| Rate for Payer: Kentucky WC Medicaid |
$4,084.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,641.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,677.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,527.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,124.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,346.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,818.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,406.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,229.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,112.68
|
| Rate for Payer: PHCS Commercial |
$11,287.20
|
| Rate for Payer: United Healthcare All Payer |
$10,346.60
|
|
|
MODULAR II-C HUMERAL STEM
|
Facility
|
IP
|
$11,757.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,527.25 |
| Max. Negotiated Rate |
$11,287.20 |
| Rate for Payer: Aetna Commercial |
$9,053.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,170.85
|
| Rate for Payer: Cash Price |
$5,878.75
|
| Rate for Payer: Cigna Commercial |
$9,758.73
|
| Rate for Payer: First Health Commercial |
$11,169.62
|
| Rate for Payer: Humana Commercial |
$9,993.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,641.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,677.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,527.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,346.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,818.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,406.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,229.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,112.68
|
| Rate for Payer: PHCS Commercial |
$11,287.20
|
| Rate for Payer: United Healthcare All Payer |
$10,346.60
|
|
|
MODULAR POST 25MM
|
Facility
|
IP
|
$8,292.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,487.75 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Aetna Commercial |
$6,385.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,468.15
|
| Rate for Payer: Cash Price |
$4,146.25
|
| Rate for Payer: Cigna Commercial |
$6,882.77
|
| Rate for Payer: First Health Commercial |
$7,877.88
|
| Rate for Payer: Humana Commercial |
$7,048.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,799.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,119.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,487.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,297.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,219.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,214.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,721.82
|
| Rate for Payer: PHCS Commercial |
$7,960.80
|
| Rate for Payer: United Healthcare All Payer |
$7,297.40
|
|
|
MODULAR POST 25MM
|
Facility
|
OP
|
$8,292.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,487.75 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Aetna Commercial |
$6,385.23
|
| Rate for Payer: Anthem Medicaid |
$2,851.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,468.15
|
| Rate for Payer: Cash Price |
$4,146.25
|
| Rate for Payer: Cigna Commercial |
$6,882.77
|
| Rate for Payer: First Health Commercial |
$7,877.88
|
| Rate for Payer: Humana Commercial |
$7,048.62
|
| Rate for Payer: Humana KY Medicaid |
$2,851.79
|
| Rate for Payer: Kentucky WC Medicaid |
$2,880.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,799.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,119.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,487.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,909.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,297.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,219.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,214.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,721.82
|
| Rate for Payer: PHCS Commercial |
$7,960.80
|
| Rate for Payer: United Healthcare All Payer |
$7,297.40
|
|
|
MODURETIC (AMILOR./HCTZ) 1TAB
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 555048302
|
| Hospital Charge Code |
25001006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
MODURETIC (AMILOR./HCTZ) 1TAB
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 555048302
|
| Hospital Charge Code |
25001006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
MOISTURIZE SKIN CREAM 118 mL
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
NDC 53329015404
|
| Hospital Charge Code |
25004461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.06
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.32
|
| Rate for Payer: First Health Commercial |
$4.94
|
| Rate for Payer: Humana Commercial |
$4.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.58
|
| Rate for Payer: Ohio Health Group HMO |
$3.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$4.99
|
| Rate for Payer: United Healthcare All Payer |
$4.58
|
|
|
MOISTURIZE SKIN CREAM 118 mL
|
Facility
|
OP
|
$5.20
|
|
|
Service Code
|
NDC 53329015404
|
| Hospital Charge Code |
25004461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.06
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.32
|
| Rate for Payer: First Health Commercial |
$4.94
|
| Rate for Payer: Humana Commercial |
$4.42
|
| Rate for Payer: Humana KY Medicaid |
$1.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.58
|
| Rate for Payer: Ohio Health Group HMO |
$3.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$4.99
|
| Rate for Payer: United Healthcare All Payer |
$4.58
|
|
|
MOISTURIZE SKIN CREAM 4 gm
|
Facility
|
OP
|
$9.26
|
|
|
Service Code
|
NDC 53329015404
|
| Hospital Charge Code |
25004462
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Aetna Commercial |
$7.13
|
| Rate for Payer: Anthem Medicaid |
$3.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.80
|
| Rate for Payer: Humana Commercial |
$7.87
|
| Rate for Payer: Humana KY Medicaid |
$3.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.15
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.39
|
| Rate for Payer: PHCS Commercial |
$8.89
|
| Rate for Payer: United Healthcare All Payer |
$8.15
|
|
|
MOISTURIZE SKIN CREAM 4 gm
|
Facility
|
IP
|
$9.26
|
|
|
Service Code
|
NDC 53329015404
|
| Hospital Charge Code |
25004462
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Aetna Commercial |
$7.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.80
|
| Rate for Payer: Humana Commercial |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.15
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.39
|
| Rate for Payer: PHCS Commercial |
$8.89
|
| Rate for Payer: United Healthcare All Payer |
$8.15
|
|
|
MOISTURIZE SKIN CREAM 59 mL
|
Facility
|
IP
|
$16.26
|
|
|
Service Code
|
NDC 53329015413
|
| Hospital Charge Code |
25004454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.68
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Cigna Commercial |
$13.50
|
| Rate for Payer: First Health Commercial |
$15.45
|
| Rate for Payer: Humana Commercial |
$13.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.31
|
| Rate for Payer: Ohio Health Group HMO |
$12.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.22
|
| Rate for Payer: PHCS Commercial |
$15.61
|
| Rate for Payer: United Healthcare All Payer |
$14.31
|
|
|
MOISTURIZE SKIN CREAM 59 mL
|
Facility
|
OP
|
$16.26
|
|
|
Service Code
|
NDC 53329015413
|
| Hospital Charge Code |
25004454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Anthem Medicaid |
$5.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.68
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Cigna Commercial |
$13.50
|
| Rate for Payer: First Health Commercial |
$15.45
|
| Rate for Payer: Humana Commercial |
$13.82
|
| Rate for Payer: Humana KY Medicaid |
$5.59
|
| Rate for Payer: Kentucky WC Medicaid |
$5.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.31
|
| Rate for Payer: Ohio Health Group HMO |
$12.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.22
|
| Rate for Payer: PHCS Commercial |
$15.61
|
| Rate for Payer: United Healthcare All Payer |
$14.31
|
|
|
MOLD DEFINITIVE IDENTIFICATION
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 87107
|
| Hospital Charge Code |
30001278
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
