|
MULTI LNK RX ULTRA STNT 4.5*38
|
Facility
|
OP
|
$4,562.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.12 |
| Max. Negotiated Rate |
$4,380.00 |
| Rate for Payer: Aetna Commercial |
$3,513.12
|
| Rate for Payer: Anthem Medicaid |
$1,569.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,558.75
|
| Rate for Payer: Cash Price |
$2,281.25
|
| Rate for Payer: Cigna Commercial |
$3,786.88
|
| Rate for Payer: First Health Commercial |
$4,334.38
|
| Rate for Payer: Humana Commercial |
$3,878.12
|
| Rate for Payer: Humana KY Medicaid |
$1,569.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,585.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,741.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,367.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,368.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,600.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,015.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$593.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,414.38
|
| Rate for Payer: PHCS Commercial |
$4,380.00
|
| Rate for Payer: United Healthcare All Payer |
$4,015.00
|
|
|
MULTI LNK RX ULTRA STNT 4.5*38
|
Facility
|
IP
|
$4,562.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$593.12 |
| Max. Negotiated Rate |
$4,380.00 |
| Rate for Payer: Aetna Commercial |
$3,513.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,558.75
|
| Rate for Payer: Cash Price |
$2,281.25
|
| Rate for Payer: Cigna Commercial |
$3,786.88
|
| Rate for Payer: First Health Commercial |
$4,334.38
|
| Rate for Payer: Humana Commercial |
$3,878.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,741.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,367.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,368.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,015.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$593.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,414.38
|
| Rate for Payer: PHCS Commercial |
$4,380.00
|
| Rate for Payer: United Healthcare All Payer |
$4,015.00
|
|
|
MULTI LUMEN 20CM 3 PORT
|
Facility
|
IP
|
$1,880.64
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.48 |
| Max. Negotiated Rate |
$1,805.41 |
| Rate for Payer: Aetna Commercial |
$1,448.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,466.90
|
| Rate for Payer: Cash Price |
$940.32
|
| Rate for Payer: Cigna Commercial |
$1,560.93
|
| Rate for Payer: First Health Commercial |
$1,786.61
|
| Rate for Payer: Humana Commercial |
$1,598.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,542.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,387.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,654.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,410.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.00
|
| Rate for Payer: PHCS Commercial |
$1,805.41
|
| Rate for Payer: United Healthcare All Payer |
$1,654.96
|
|
|
MULTI LUMEN 20CM 3 PORT
|
Facility
|
OP
|
$1,880.64
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.48 |
| Max. Negotiated Rate |
$1,805.41 |
| Rate for Payer: Aetna Commercial |
$1,448.09
|
| Rate for Payer: Anthem Medicaid |
$646.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,466.90
|
| Rate for Payer: Cash Price |
$940.32
|
| Rate for Payer: Cigna Commercial |
$1,560.93
|
| Rate for Payer: First Health Commercial |
$1,786.61
|
| Rate for Payer: Humana Commercial |
$1,598.54
|
| Rate for Payer: Humana KY Medicaid |
$646.75
|
| Rate for Payer: Kentucky WC Medicaid |
$653.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,542.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,387.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$659.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,654.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,410.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.00
|
| Rate for Payer: PHCS Commercial |
$1,805.41
|
| Rate for Payer: United Healthcare All Payer |
$1,654.96
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC
|
Facility
|
IP
|
$13,888.10
|
|
|
Service Code
|
MSDRG 059
|
| Min. Negotiated Rate |
$9,424.07 |
| Max. Negotiated Rate |
$13,888.10 |
| Rate for Payer: Anthem Medicaid |
$9,424.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,920.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,888.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,392.09
|
| Rate for Payer: Humana KY Medicaid |
$9,424.07
|
| Rate for Payer: Humana Medicare Advantage |
$9,920.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,518.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,904.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,612.55
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC
|
Facility
|
IP
|
$20,213.33
|
|
|
Service Code
|
MSDRG 058
|
| Min. Negotiated Rate |
$13,716.19 |
| Max. Negotiated Rate |
$20,213.33 |
| Rate for Payer: Anthem Medicaid |
$13,716.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,438.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20,213.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$19,491.42
|
| Rate for Payer: Humana KY Medicaid |
$13,716.19
|
| Rate for Payer: Humana Medicare Advantage |
$14,438.09
|
| Rate for Payer: Kentucky WC Medicaid |
$13,853.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,325.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,990.51
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC
|
Facility
|
IP
|
$10,497.98
|
|
|
Service Code
|
MSDRG 060
|
| Min. Negotiated Rate |
$7,123.63 |
| Max. Negotiated Rate |
$10,497.98 |
| Rate for Payer: Anthem Medicaid |
$7,123.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,498.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,497.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,123.06
|
| Rate for Payer: Humana KY Medicaid |
$7,123.63
|
| Rate for Payer: Humana Medicare Advantage |
$7,498.56
|
| Rate for Payer: Kentucky WC Medicaid |
$7,194.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,998.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,266.10
|
|
|
MUMPS IGG
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS 86735
|
| Hospital Charge Code |
30001194
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.19
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
MUMPS IGG
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS 86735
|
| Hospital Charge Code |
30001194
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem Medicaid |
$13.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.05
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Humana KY Medicaid |
$13.05
|
| Rate for Payer: Humana Medicare Advantage |
$13.05
|
| Rate for Payer: Kentucky WC Medicaid |
$13.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.19
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
MUPIROCIN 2% 1GM UD OINTMENT
|
Facility
|
IP
|
$11.57
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
25003240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.11 |
| Rate for Payer: Humana Commercial |
$9.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.18
|
| Rate for Payer: Ohio Health Group HMO |
$8.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$11.11
|
| Rate for Payer: United Healthcare All Payer |
$10.18
|
| Rate for Payer: Aetna Commercial |
$8.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.02
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: First Health Commercial |
$10.99
|
|
|
MUPIROCIN 2% 1GM UD OINTMENT
|
Facility
|
OP
|
$11.57
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
25003240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.11 |
| Rate for Payer: Aetna Commercial |
$8.91
|
| Rate for Payer: Anthem Medicaid |
$3.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.02
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: First Health Commercial |
$10.99
|
| Rate for Payer: Humana Commercial |
$9.83
|
| Rate for Payer: Humana KY Medicaid |
$3.98
|
| Rate for Payer: Kentucky WC Medicaid |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.18
|
| Rate for Payer: Ohio Health Group HMO |
$8.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$11.11
|
| Rate for Payer: United Healthcare All Payer |
$10.18
|
|
|
MURO 128 5% DROPS 15ML
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 536125494
|
| Hospital Charge Code |
25003242
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
MURO 128 5% DROPS 15ML
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 536125494
|
| Hospital Charge Code |
25003242
|
|
Hospital Revenue Code
|
259
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
MURO 128 EYE OINT 3.5 GM
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 536125391
|
| Hospital Charge Code |
25001019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna Commercial |
$0.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna Commercial |
$0.45
|
| Rate for Payer: First Health Commercial |
$0.51
|
| Rate for Payer: Humana Commercial |
$0.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.48
|
| Rate for Payer: Ohio Health Group HMO |
$0.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.17
|
| Rate for Payer: PHCS Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.48
|
|
|
MURO 128 EYE OINT 3.5 GM
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 536125391
|
| Hospital Charge Code |
25001019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna Commercial |
$0.42
|
| Rate for Payer: Anthem Medicaid |
$0.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna Commercial |
$0.45
|
| Rate for Payer: First Health Commercial |
$0.51
|
| Rate for Payer: Humana Commercial |
$0.46
|
| Rate for Payer: Humana KY Medicaid |
$0.19
|
| Rate for Payer: Kentucky WC Medicaid |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.48
|
| Rate for Payer: Ohio Health Group HMO |
$0.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.17
|
| Rate for Payer: PHCS Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.48
|
|
|
MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)
|
Facility
|
OP
|
$4,343.37
|
|
|
Service Code
|
CPT 15733
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,102.41 |
| Max. Negotiated Rate |
$4,343.37 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS
|
Facility
|
IP
|
$8,566.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
76100205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,113.67 |
| Max. Negotiated Rate |
$8,224.00 |
| Rate for Payer: Aetna Commercial |
$6,596.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,682.00
|
| Rate for Payer: Cash Price |
$4,283.34
|
| Rate for Payer: Cigna Commercial |
$7,110.34
|
| Rate for Payer: First Health Commercial |
$8,138.34
|
| Rate for Payer: Humana Commercial |
$7,281.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,024.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,322.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,570.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,538.67
|
| Rate for Payer: Ohio Health Group HMO |
$6,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,713.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,113.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,655.67
|
| Rate for Payer: PHCS Commercial |
$8,224.00
|
| Rate for Payer: United Healthcare All Payer |
$7,538.67
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS
|
Professional
|
Both
|
$8,566.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
76100205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$770.16 |
| Max. Negotiated Rate |
$8,566.67 |
| Rate for Payer: Aetna Commercial |
$1,970.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$770.16
|
| Rate for Payer: Anthem Medicaid |
$1,073.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$8,566.67
|
| Rate for Payer: Cash Price |
$4,283.34
|
| Rate for Payer: Cash Price |
$4,283.34
|
| Rate for Payer: Cigna Commercial |
$1,869.90
|
| Rate for Payer: Healthspan PPO |
$1,756.19
|
| Rate for Payer: Humana Medicaid |
$1,073.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,697.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,094.84
|
| Rate for Payer: Molina Healthcare Passport |
$1,073.37
|
| Rate for Payer: Multiplan PHCS |
$5,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,996.67
|
| Rate for Payer: UHCCP Medicaid |
$808.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,084.10
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS
|
Facility
|
OP
|
$8,566.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
76100205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,113.67 |
| Max. Negotiated Rate |
$8,224.00 |
| Rate for Payer: Aetna Commercial |
$6,596.34
|
| Rate for Payer: Anthem Medicaid |
$2,946.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,682.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$4,283.34
|
| Rate for Payer: Cash Price |
$4,283.34
|
| Rate for Payer: Cigna Commercial |
$7,110.34
|
| Rate for Payer: First Health Commercial |
$8,138.34
|
| Rate for Payer: Humana Commercial |
$7,281.67
|
| Rate for Payer: Humana KY Medicaid |
$2,946.08
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,976.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,024.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,322.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,005.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,538.67
|
| Rate for Payer: Ohio Health Group HMO |
$6,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,713.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,113.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,655.67
|
| Rate for Payer: PHCS Commercial |
$8,224.00
|
| Rate for Payer: United Healthcare All Payer |
$7,538.67
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS(P
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
761P0205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$770.16 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$1,869.90
|
| Rate for Payer: Healthspan PPO |
$1,756.19
|
| Rate for Payer: Aetna Commercial |
$1,970.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$770.16
|
| Rate for Payer: Anthem Medicaid |
$1,073.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,600.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Humana Medicaid |
$1,073.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,697.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,094.84
|
| Rate for Payer: Molina Healthcare Passport |
$1,073.37
|
| Rate for Payer: Multiplan PHCS |
$1,560.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,820.00
|
| Rate for Payer: UHCCP Medicaid |
$808.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,084.10
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS(T
|
Facility
|
IP
|
$5,966.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
761T0205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$775.67 |
| Max. Negotiated Rate |
$5,728.00 |
| Rate for Payer: Aetna Commercial |
$4,594.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,654.00
|
| Rate for Payer: Cash Price |
$2,983.34
|
| Rate for Payer: Cigna Commercial |
$4,952.34
|
| Rate for Payer: First Health Commercial |
$5,668.34
|
| Rate for Payer: Humana Commercial |
$5,071.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,892.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,403.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,790.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,250.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,475.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,193.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$775.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,849.67
|
| Rate for Payer: PHCS Commercial |
$5,728.00
|
| Rate for Payer: United Healthcare All Payer |
$5,250.67
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS(T
|
Facility
|
OP
|
$5,966.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
761T0205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$775.67 |
| Max. Negotiated Rate |
$5,728.00 |
| Rate for Payer: Aetna Commercial |
$4,594.34
|
| Rate for Payer: Anthem Medicaid |
$2,051.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,654.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,983.34
|
| Rate for Payer: Cash Price |
$2,983.34
|
| Rate for Payer: Cigna Commercial |
$4,952.34
|
| Rate for Payer: First Health Commercial |
$5,668.34
|
| Rate for Payer: Humana Commercial |
$5,071.67
|
| Rate for Payer: Humana KY Medicaid |
$2,051.94
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,072.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,892.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,403.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,093.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,250.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,475.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,193.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$775.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,849.67
|
| Rate for Payer: PHCS Commercial |
$5,728.00
|
| Rate for Payer: United Healthcare All Payer |
$5,250.67
|
|
|
MUSCLE-SKIN GRAFT - ARM
|
Facility
|
OP
|
$7,104.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
76100206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$923.63 |
| Max. Negotiated Rate |
$6,820.68 |
| Rate for Payer: Aetna Commercial |
$5,470.76
|
| Rate for Payer: Anthem Medicaid |
$2,443.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,541.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,552.44
|
| Rate for Payer: Cash Price |
$3,552.44
|
| Rate for Payer: Cigna Commercial |
$5,897.05
|
| Rate for Payer: First Health Commercial |
$6,749.64
|
| Rate for Payer: Humana Commercial |
$6,039.15
|
| Rate for Payer: Humana KY Medicaid |
$2,443.37
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.29
|
| Rate for Payer: Ohio Health Group HMO |
$5,328.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,202.51
|
| Rate for Payer: PHCS Commercial |
$6,820.68
|
| Rate for Payer: United Healthcare All Payer |
$6,252.29
|
|
|
MUSCLE-SKIN GRAFT - ARM
|
Facility
|
IP
|
$7,104.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
76100206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$923.63 |
| Max. Negotiated Rate |
$6,820.68 |
| Rate for Payer: Aetna Commercial |
$5,470.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,541.81
|
| Rate for Payer: Cash Price |
$3,552.44
|
| Rate for Payer: Cigna Commercial |
$5,897.05
|
| Rate for Payer: First Health Commercial |
$6,749.64
|
| Rate for Payer: Humana Commercial |
$6,039.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.29
|
| Rate for Payer: Ohio Health Group HMO |
$5,328.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,202.51
|
| Rate for Payer: PHCS Commercial |
$6,820.68
|
| Rate for Payer: United Healthcare All Payer |
$6,252.29
|
|
|
MUSCLE-SKIN GRAFT - ARM
|
Professional
|
Both
|
$7,104.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
76100206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$670.03 |
| Max. Negotiated Rate |
$7,104.88 |
| Rate for Payer: Aetna Commercial |
$1,708.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$670.03
|
| Rate for Payer: Anthem Medicaid |
$955.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,104.88
|
| Rate for Payer: Cash Price |
$3,552.44
|
| Rate for Payer: Cash Price |
$3,552.44
|
| Rate for Payer: Cigna Commercial |
$1,642.37
|
| Rate for Payer: Healthspan PPO |
$1,558.68
|
| Rate for Payer: Humana Medicaid |
$955.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,460.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$975.07
|
| Rate for Payer: Molina Healthcare Passport |
$955.95
|
| Rate for Payer: Multiplan PHCS |
$4,262.93
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,973.42
|
| Rate for Payer: UHCCP Medicaid |
$703.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.51
|
|
