|
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 |
$0.16 |
| 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 |
$0.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.37
|
| 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
|
$4,735.72
|
|
|
Service Code
|
CPT 15733
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,382.66 |
| Max. Negotiated Rate |
$4,735.72 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS
|
Facility
|
IP
|
$8,566.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
76100205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,570.00 |
| 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 |
$6,853.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,453.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,911.00
|
| 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 |
$5,140.00 |
| Rate for Payer: Aetna Commercial |
$1,970.50
|
| Rate for Payer: Ambetter Exchange |
$1,421.48
|
| 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 Individual/Medicaid |
$1,421.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,421.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,705.78
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,421.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,421.48
|
| 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 |
$1,847.92
|
| Rate for Payer: UHCCP Medicaid |
$808.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,084.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,421.48
|
|
|
MUSCLE MYO OR FASCOCUTANEOUS
|
Facility
|
OP
|
$8,566.67
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
76100205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,946.08 |
| 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 |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,682.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| 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 |
$3,382.66
|
| 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 |
$4,059.19
|
| 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 |
$6,853.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,453.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,911.00
|
| 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 |
$1,970.50 |
| Rate for Payer: Aetna Commercial |
$1,970.50
|
| Rate for Payer: Ambetter Exchange |
$1,421.48
|
| 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 Individual/Medicaid |
$1,421.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,421.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,705.78
|
| Rate for Payer: Cash Price |
$1,300.00
|
| 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: Humana Medicaid |
$1,073.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,697.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,421.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,421.48
|
| 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 |
$1,847.92
|
| Rate for Payer: UHCCP Medicaid |
$808.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,084.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,421.48
|
|
|
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 |
$1,790.00 |
| 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 |
$4,773.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,191.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,117.00
|
| 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 |
$2,051.94 |
| 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 |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,654.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| 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 |
$3,382.66
|
| 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 |
$4,059.19
|
| 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 |
$4,773.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,191.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,117.00
|
| Rate for Payer: PHCS Commercial |
$5,728.00
|
| Rate for Payer: United Healthcare All Payer |
$5,250.67
|
|
|
MUSCLE-SKIN GRAFT - ARM
|
Facility
|
IP
|
$7,104.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
76100206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,131.46 |
| 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 |
$5,683.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.37
|
| Rate for Payer: PHCS Commercial |
$6,820.68
|
| Rate for Payer: United Healthcare All Payer |
$6,252.29
|
|
|
MUSCLE-SKIN GRAFT - ARM
|
Facility
|
OP
|
$7,104.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
76100206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,541.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$5,683.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.37
|
| 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 |
$4,262.93 |
| Rate for Payer: Aetna Commercial |
$1,708.51
|
| Rate for Payer: Ambetter Exchange |
$1,145.90
|
| 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 Individual/Medicaid |
$1,145.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,145.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,375.08
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,145.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,145.90
|
| 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 |
$1,489.67
|
| Rate for Payer: UHCCP Medicaid |
$703.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,145.90
|
|
|
MUSCLE-SKIN GRAFT - ARM(P
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
761P0206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$670.03 |
| Max. Negotiated Rate |
$1,708.51 |
| Rate for Payer: Aetna Commercial |
$1,708.51
|
| Rate for Payer: Ambetter Exchange |
$1,145.90
|
| 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 Individual/Medicaid |
$1,145.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,145.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,375.08
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,145.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,145.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$975.07
|
| Rate for Payer: Molina Healthcare Passport |
$955.95
|
| Rate for Payer: Multiplan PHCS |
$1,560.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,489.67
|
| Rate for Payer: UHCCP Medicaid |
$703.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,145.90
|
|
|
MUSCLE-SKIN GRAFT - ARM(T
|
Facility
|
OP
|
$4,504.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
761T0206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,549.23 |
| Max. Negotiated Rate |
$4,324.68 |
| Rate for Payer: Aetna Commercial |
$3,468.76
|
| Rate for Payer: Anthem Medicaid |
$1,549.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,513.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,252.44
|
| Rate for Payer: Cash Price |
$2,252.44
|
| Rate for Payer: Cigna Commercial |
$3,739.05
|
| Rate for Payer: First Health Commercial |
$4,279.64
|
| Rate for Payer: Humana Commercial |
$3,829.15
|
| Rate for Payer: Humana KY Medicaid |
$1,549.23
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,565.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,694.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,324.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,580.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,964.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,378.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,603.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,919.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,108.37
|
| Rate for Payer: PHCS Commercial |
$4,324.68
|
| Rate for Payer: United Healthcare All Payer |
$3,964.29
|
|
|
MUSCLE-SKIN GRAFT - ARM(T
|
Facility
|
IP
|
$4,504.88
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
761T0206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,351.46 |
| Max. Negotiated Rate |
$4,324.68 |
| Rate for Payer: Aetna Commercial |
$3,468.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,513.81
|
| Rate for Payer: Cash Price |
$2,252.44
|
| Rate for Payer: Cigna Commercial |
$3,739.05
|
| Rate for Payer: First Health Commercial |
$4,279.64
|
| Rate for Payer: Humana Commercial |
$3,829.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,694.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,324.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,351.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,964.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,378.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,603.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,919.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,108.37
|
| Rate for Payer: PHCS Commercial |
$4,324.68
|
| Rate for Payer: United Healthcare All Payer |
$3,964.29
|
|
|
MUSCLE-SKIN GRAFT LEG
|
Facility
|
OP
|
$8,250.75
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
76100207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,837.43 |
| Max. Negotiated Rate |
$7,920.72 |
| Rate for Payer: Aetna Commercial |
$6,353.08
|
| Rate for Payer: Anthem Medicaid |
$2,837.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,435.59
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Cash Price |
$4,125.38
|
| Rate for Payer: Cash Price |
$4,125.38
|
| Rate for Payer: Cigna Commercial |
$6,848.12
|
| Rate for Payer: First Health Commercial |
$7,838.21
|
| Rate for Payer: Humana Commercial |
$7,013.14
|
| Rate for Payer: Humana KY Medicaid |
$2,837.43
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Kentucky WC Medicaid |
$2,866.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,765.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,089.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,894.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,260.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,188.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,600.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,178.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.02
|
| Rate for Payer: PHCS Commercial |
$7,920.72
|
| Rate for Payer: United Healthcare All Payer |
$7,260.66
|
|
|
MUSCLE-SKIN GRAFT LEG
|
Professional
|
Both
|
$8,250.75
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
76100207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,950.45 |
| Rate for Payer: Aetna Commercial |
$1,862.28
|
| Rate for Payer: Ambetter Exchange |
$1,192.52
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$652.16
|
| Rate for Payer: Anthem Medicaid |
$721.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,192.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,192.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,431.02
|
| Rate for Payer: Cash Price |
$4,125.38
|
| Rate for Payer: Cash Price |
$4,125.38
|
| Rate for Payer: Cigna Commercial |
$1,786.99
|
| Rate for Payer: Healthspan PPO |
$1,666.66
|
| Rate for Payer: Humana Medicaid |
$721.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,586.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,192.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,192.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$735.59
|
| Rate for Payer: Molina Healthcare Passport |
$721.17
|
| Rate for Payer: Multiplan PHCS |
$4,950.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,550.28
|
| Rate for Payer: UHCCP Medicaid |
$684.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$728.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,192.52
|
|
|
MUSCLE-SKIN GRAFT LEG
|
Facility
|
IP
|
$8,250.75
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
76100207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,475.22 |
| Max. Negotiated Rate |
$7,920.72 |
| Rate for Payer: Aetna Commercial |
$6,353.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,435.59
|
| Rate for Payer: Cash Price |
$4,125.38
|
| Rate for Payer: Cigna Commercial |
$6,848.12
|
| Rate for Payer: First Health Commercial |
$7,838.21
|
| Rate for Payer: Humana Commercial |
$7,013.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,765.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,089.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,475.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,260.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,188.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,600.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,178.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.02
|
| Rate for Payer: PHCS Commercial |
$7,920.72
|
| Rate for Payer: United Healthcare All Payer |
$7,260.66
|
|
|
MUSCLE-SKIN GRAFT LEG(P
|
Professional
|
Both
|
$2,475.00
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
761P0207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$1,862.28 |
| Rate for Payer: Aetna Commercial |
$1,862.28
|
| Rate for Payer: Ambetter Exchange |
$1,192.52
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$652.16
|
| Rate for Payer: Anthem Medicaid |
$721.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,192.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,192.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,431.02
|
| Rate for Payer: Cash Price |
$1,237.50
|
| Rate for Payer: Cash Price |
$1,237.50
|
| Rate for Payer: Cigna Commercial |
$1,786.99
|
| Rate for Payer: Healthspan PPO |
$1,666.66
|
| Rate for Payer: Humana Medicaid |
$721.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,586.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,192.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,192.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$735.59
|
| Rate for Payer: Molina Healthcare Passport |
$721.17
|
| Rate for Payer: Multiplan PHCS |
$1,485.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,550.28
|
| Rate for Payer: UHCCP Medicaid |
$684.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$728.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,192.52
|
|
|
MUSCLE-SKIN GRAFT LEG(T
|
Facility
|
OP
|
$5,775.75
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
761T0207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,986.28 |
| Max. Negotiated Rate |
$5,544.72 |
| Rate for Payer: Aetna Commercial |
$4,447.33
|
| Rate for Payer: Anthem Medicaid |
$1,986.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,505.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Cash Price |
$2,887.88
|
| Rate for Payer: Cash Price |
$2,887.88
|
| Rate for Payer: Cigna Commercial |
$4,793.87
|
| Rate for Payer: First Health Commercial |
$5,486.96
|
| Rate for Payer: Humana Commercial |
$4,909.39
|
| Rate for Payer: Humana KY Medicaid |
$1,986.28
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Kentucky WC Medicaid |
$2,006.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,736.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,262.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,026.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,082.66
|
| Rate for Payer: Ohio Health Group HMO |
$4,331.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,620.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,024.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,985.27
|
| Rate for Payer: PHCS Commercial |
$5,544.72
|
| Rate for Payer: United Healthcare All Payer |
$5,082.66
|
|
|
MUSCLE-SKIN GRAFT LEG(T
|
Facility
|
IP
|
$5,775.75
|
|
|
Service Code
|
HCPCS 15738
|
| Hospital Charge Code |
761T0207
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,732.72 |
| Max. Negotiated Rate |
$5,544.72 |
| Rate for Payer: Aetna Commercial |
$4,447.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,505.09
|
| Rate for Payer: Cash Price |
$2,887.88
|
| Rate for Payer: Cigna Commercial |
$4,793.87
|
| Rate for Payer: First Health Commercial |
$5,486.96
|
| Rate for Payer: Humana Commercial |
$4,909.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,736.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,262.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,732.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,082.66
|
| Rate for Payer: Ohio Health Group HMO |
$4,331.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,620.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,024.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,985.27
|
| Rate for Payer: PHCS Commercial |
$5,544.72
|
| Rate for Payer: United Healthcare All Payer |
$5,082.66
|
|
|
MUSCLE TEST CRAN NERVE BILAT
|
Facility
|
OP
|
$1,650.00
|
|
|
Service Code
|
HCPCS 95868
|
| Hospital Charge Code |
92200020
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$287.73 |
| Max. Negotiated Rate |
$1,584.00 |
| Rate for Payer: Aetna Commercial |
$1,270.50
|
| Rate for Payer: Anthem Medicaid |
$567.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$825.00
|
| Rate for Payer: Cash Price |
$825.00
|
| Rate for Payer: Cigna Commercial |
$1,369.50
|
| Rate for Payer: First Health Commercial |
$1,567.50
|
| Rate for Payer: Humana Commercial |
$1,402.50
|
| Rate for Payer: Humana KY Medicaid |
$567.43
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$573.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,217.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$578.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,237.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,435.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,138.50
|
| Rate for Payer: PHCS Commercial |
$1,584.00
|
| Rate for Payer: United Healthcare All Payer |
$1,452.00
|
|
|
MUSCLE TEST CRAN NERVE BILAT
|
Professional
|
Both
|
$1,650.00
|
|
|
Service Code
|
HCPCS 95868
|
| Hospital Charge Code |
92200020
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$71.98 |
| Max. Negotiated Rate |
$990.00 |
| Rate for Payer: Aetna Commercial |
$149.10
|
| Rate for Payer: Ambetter Exchange |
$114.10
|
| Rate for Payer: Anthem Medicaid |
$99.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.92
|
| Rate for Payer: Cash Price |
$825.00
|
| Rate for Payer: Cash Price |
$825.00
|
| Rate for Payer: Cigna Commercial |
$141.32
|
| Rate for Payer: Healthspan PPO |
$131.33
|
| Rate for Payer: Humana Medicaid |
$99.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.14
|
| Rate for Payer: Molina Healthcare Passport |
$99.16
|
| Rate for Payer: Multiplan PHCS |
$990.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.33
|
| Rate for Payer: UHCCP Medicaid |
$577.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.10
|
|
|
MUSCLE TEST CRAN NERVE BILAT
|
Facility
|
IP
|
$1,650.00
|
|
|
Service Code
|
HCPCS 95868
|
| Hospital Charge Code |
92200020
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$495.00 |
| Max. Negotiated Rate |
$1,584.00 |
| Rate for Payer: Aetna Commercial |
$1,270.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,287.00
|
| Rate for Payer: Cash Price |
$825.00
|
| Rate for Payer: Cigna Commercial |
$1,369.50
|
| Rate for Payer: First Health Commercial |
$1,567.50
|
| Rate for Payer: Humana Commercial |
$1,402.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,353.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,217.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,452.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,237.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,435.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,138.50
|
| Rate for Payer: PHCS Commercial |
$1,584.00
|
| Rate for Payer: United Healthcare All Payer |
$1,452.00
|
|
|
MUSCLE TEST CRAN NERVE BILAT(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 95868
|
| Hospital Charge Code |
922P0020
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$149.10 |
| Rate for Payer: Aetna Commercial |
$149.10
|
| Rate for Payer: Ambetter Exchange |
$114.10
|
| Rate for Payer: Anthem Medicaid |
$99.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.92
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$141.32
|
| Rate for Payer: Healthspan PPO |
$131.33
|
| Rate for Payer: Humana Medicaid |
$99.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.14
|
| Rate for Payer: Molina Healthcare Passport |
$99.16
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.33
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.10
|
|
|
MUSCLE TEST CRAN NERVE BILAT(T
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 95868
|
| Hospital Charge Code |
922T0020
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
