|
NEUROPLASTY
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
NEUROPLASTY
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$640.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$263.04
|
| Rate for Payer: Anthem Medicaid |
$284.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$609.80
|
| Rate for Payer: Healthspan PPO |
$501.51
|
| Rate for Payer: Humana Medicaid |
$284.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$530.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.47
|
| Rate for Payer: Molina Healthcare Passport |
$284.77
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$276.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.62
|
|
|
NEUROPLASTY
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
76102364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL
|
Facility
|
OP
|
$2,337.51
|
|
|
Service Code
|
CPT 64721
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,669.65 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW
|
Facility
|
OP
|
$2,337.51
|
|
|
Service Code
|
CPT 64718
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,669.65 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
|
|
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST
|
Facility
|
OP
|
$2,337.51
|
|
|
Service Code
|
CPT 64719
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,669.65 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
|
|
NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED
|
Facility
|
OP
|
$2,337.51
|
|
|
Service Code
|
CPT 64708
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,669.65 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
|
|
NEUROPLASTY; NERVE HAND/FOOT
|
Facility
|
OP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$2,337.51 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem Medicaid |
$398.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Humana KY Medicaid |
$398.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Kentucky WC Medicaid |
$402.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$406.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.60
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
NEUROPLASTY; NERVE HAND/FOOT
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.57 |
| Max. Negotiated Rate |
$1,160.00 |
| Rate for Payer: Aetna Commercial |
$529.75
|
| Rate for Payer: Anthem Medicaid |
$292.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,160.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$481.06
|
| Rate for Payer: Healthspan PPO |
$413.61
|
| Rate for Payer: Humana Medicaid |
$292.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.42
|
| Rate for Payer: Molina Healthcare Passport |
$292.57
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$812.00
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.50
|
|
|
NEUROPLASTY; NERVE HAND/FOOT
|
Facility
|
IP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$1,113.60 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.60
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
NEUROPLASTY; NERVE HAND/FOOT(P
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
761P2360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.57 |
| Max. Negotiated Rate |
$1,160.00 |
| Rate for Payer: Aetna Commercial |
$529.75
|
| Rate for Payer: Anthem Medicaid |
$292.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,160.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$481.06
|
| Rate for Payer: Healthspan PPO |
$413.61
|
| Rate for Payer: Humana Medicaid |
$292.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.42
|
| Rate for Payer: Molina Healthcare Passport |
$292.57
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$812.00
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.50
|
|
|
NEUROPLASTY(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
761P2364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$640.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$263.04
|
| Rate for Payer: Anthem Medicaid |
$284.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$609.80
|
| Rate for Payer: Healthspan PPO |
$501.51
|
| Rate for Payer: Humana Medicaid |
$284.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$530.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.47
|
| Rate for Payer: Molina Healthcare Passport |
$284.77
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$276.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.62
|
|
|
NEUROSES EXCEPT DEPRESSIVE
|
Facility
|
IP
|
$10,988.12
|
|
|
Service Code
|
MSDRG 882
|
| Min. Negotiated Rate |
$7,456.23 |
| Max. Negotiated Rate |
$10,988.12 |
| Rate for Payer: Anthem Medicaid |
$7,456.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,848.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,988.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,595.69
|
| Rate for Payer: Humana KY Medicaid |
$7,456.23
|
| Rate for Payer: Humana Medicare Advantage |
$7,848.66
|
| Rate for Payer: Kentucky WC Medicaid |
$7,530.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,418.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,605.35
|
|
|
NEUROSTIMULATOR 3058
|
Facility
|
OP
|
$71,548.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,301.24 |
| Max. Negotiated Rate |
$68,686.08 |
| Rate for Payer: Aetna Commercial |
$55,091.96
|
| Rate for Payer: Anthem Medicaid |
$24,605.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,807.44
|
| Rate for Payer: Cash Price |
$35,774.00
|
| Rate for Payer: Cigna Commercial |
$59,384.84
|
| Rate for Payer: First Health Commercial |
$67,970.60
|
| Rate for Payer: Humana Commercial |
$60,815.80
|
| Rate for Payer: Humana KY Medicaid |
$24,605.36
|
| Rate for Payer: Kentucky WC Medicaid |
$24,855.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,669.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,802.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,464.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,099.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,962.24
|
| Rate for Payer: Ohio Health Group HMO |
$53,661.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,301.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,179.88
|
| Rate for Payer: PHCS Commercial |
$68,686.08
|
| Rate for Payer: United Healthcare All Payer |
$62,962.24
|
|
|
NEUROSTIMULATOR 3058
|
Facility
|
IP
|
$71,548.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,301.24 |
| Max. Negotiated Rate |
$68,686.08 |
| Rate for Payer: Aetna Commercial |
$55,091.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,807.44
|
| Rate for Payer: Cash Price |
$35,774.00
|
| Rate for Payer: Cigna Commercial |
$59,384.84
|
| Rate for Payer: First Health Commercial |
$67,970.60
|
| Rate for Payer: Humana Commercial |
$60,815.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,669.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,802.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,464.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,962.24
|
| Rate for Payer: Ohio Health Group HMO |
$53,661.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,301.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,179.88
|
| Rate for Payer: PHCS Commercial |
$68,686.08
|
| Rate for Payer: United Healthcare All Payer |
$62,962.24
|
|
|
NEUTRA-PHOS POWDER 1.25GM/1EA
|
Facility
|
IP
|
$4.74
|
|
|
Service Code
|
NDC 60258000601
|
| Hospital Charge Code |
25001069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEUTRA-PHOS POWDER 1.25GM/1EA
|
Facility
|
OP
|
$4.74
|
|
|
Service Code
|
NDC 60258000601
|
| Hospital Charge Code |
25001069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEVANAC 0.1% EYE DROPS 3ML
|
Facility
|
OP
|
$15.57
|
|
|
Service Code
|
NDC 78077803
|
| Hospital Charge Code |
25003268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.14
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cigna Commercial |
$12.92
|
| Rate for Payer: First Health Commercial |
$14.79
|
| Rate for Payer: Humana Commercial |
$13.23
|
| Rate for Payer: Humana KY Medicaid |
$5.35
|
| Rate for Payer: Kentucky WC Medicaid |
$5.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.70
|
| Rate for Payer: Ohio Health Group HMO |
$11.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.83
|
| Rate for Payer: PHCS Commercial |
$14.95
|
| Rate for Payer: United Healthcare All Payer |
$13.70
|
|
|
NEVANAC 0.1% EYE DROPS 3ML
|
Facility
|
IP
|
$15.57
|
|
|
Service Code
|
NDC 78077803
|
| Hospital Charge Code |
25003268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.14
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cigna Commercial |
$12.92
|
| Rate for Payer: First Health Commercial |
$14.79
|
| Rate for Payer: Humana Commercial |
$13.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.70
|
| Rate for Payer: Ohio Health Group HMO |
$11.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.83
|
| Rate for Payer: PHCS Commercial |
$14.95
|
| Rate for Payer: United Healthcare All Payer |
$13.70
|
|
|
NEWBORN METABOLIC SCREEN PKU
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS 84030
|
| Hospital Charge Code |
30000469
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.64 |
| Max. Negotiated Rate |
$122.88 |
| Rate for Payer: Aetna Commercial |
$98.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.78
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna Commercial |
$106.24
|
| Rate for Payer: First Health Commercial |
$121.60
|
| Rate for Payer: Humana Commercial |
$108.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.64
|
| Rate for Payer: Ohio Health Group HMO |
$96.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.68
|
| Rate for Payer: PHCS Commercial |
$122.88
|
| Rate for Payer: United Healthcare All Payer |
$112.64
|
|
|
NEWBORN METABOLIC SCREEN PKU
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS 84030
|
| Hospital Charge Code |
30000469
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$122.88 |
| Rate for Payer: Aetna Commercial |
$98.56
|
| Rate for Payer: Anthem Medicaid |
$5.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.50
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna Commercial |
$106.24
|
| Rate for Payer: First Health Commercial |
$121.60
|
| Rate for Payer: Humana Commercial |
$108.80
|
| Rate for Payer: Humana KY Medicaid |
$5.50
|
| Rate for Payer: Humana Medicare Advantage |
$5.50
|
| Rate for Payer: Kentucky WC Medicaid |
$5.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.64
|
| Rate for Payer: Ohio Health Group HMO |
$96.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.68
|
| Rate for Payer: PHCS Commercial |
$122.88
|
| Rate for Payer: United Healthcare All Payer |
$112.64
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
IP
|
$680.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$204.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
OP
|
$680.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem Medicaid |
$233.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Humana KY Medicaid |
$233.85
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$236.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$238.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
NEW PT HIGH LEVEL 4
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$102.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$680.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$211.74
|
| Rate for Payer: Healthspan PPO |
$165.14
|
| Rate for Payer: Humana Medicaid |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.85
|
| Rate for Payer: Molina Healthcare Passport |
$102.79
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$476.00
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: United Healthcare Non-Options |
$124.61
|
| Rate for Payer: United Healthcare Options |
$102.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.82
|
|
|
NEW PT HIGH LEVEL 4(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
510P0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$102.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$211.74
|
| Rate for Payer: Healthspan PPO |
$165.14
|
| Rate for Payer: Humana Medicaid |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.85
|
| Rate for Payer: Molina Healthcare Passport |
$102.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: United Healthcare Non-Options |
$124.61
|
| Rate for Payer: United Healthcare Options |
$102.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.82
|
|
