|
ORCHIOPEXY INGUN/SCROT APPR
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
HCPCS 54640
|
| Hospital Charge Code |
36001274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$220.10 |
| Max. Negotiated Rate |
$4,565.09 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem Medicaid |
$220.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,260.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,565.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,402.05
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Humana KY Medicaid |
$220.10
|
| Rate for Payer: Humana Medicare Advantage |
$3,260.78
|
| Rate for Payer: Kentucky WC Medicaid |
$222.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
ORENCIA 10MG(ABATACEPT)250MG V
|
Facility
|
IP
|
$8,249.50
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
25001820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,474.85 |
| Max. Negotiated Rate |
$7,919.52 |
| Rate for Payer: Aetna Commercial |
$6,352.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,434.61
|
| Rate for Payer: Cash Price |
$4,124.75
|
| Rate for Payer: Cigna Commercial |
$6,847.09
|
| Rate for Payer: First Health Commercial |
$7,837.02
|
| Rate for Payer: Humana Commercial |
$7,012.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,764.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,088.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,474.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,259.56
|
| Rate for Payer: Ohio Health Group HMO |
$6,187.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,599.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,177.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,692.15
|
| Rate for Payer: PHCS Commercial |
$7,919.52
|
| Rate for Payer: United Healthcare All Payer |
$7,259.56
|
|
|
ORENCIA 10MG(ABATACEPT)250MG V
|
Facility
|
OP
|
$8,249.50
|
|
|
Service Code
|
HCPCS J0129
|
| Hospital Charge Code |
25001820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.49 |
| Max. Negotiated Rate |
$7,919.52 |
| Rate for Payer: Aetna Commercial |
$6,352.11
|
| Rate for Payer: Anthem Medicaid |
$2,837.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$44.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,434.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$62.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.06
|
| Rate for Payer: Cash Price |
$4,124.75
|
| Rate for Payer: Cash Price |
$4,124.75
|
| Rate for Payer: Cigna Commercial |
$6,847.09
|
| Rate for Payer: First Health Commercial |
$7,837.02
|
| Rate for Payer: Humana Commercial |
$7,012.07
|
| Rate for Payer: Humana KY Medicaid |
$2,837.00
|
| Rate for Payer: Humana Medicare Advantage |
$44.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,865.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,764.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,088.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,893.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,259.56
|
| Rate for Payer: Ohio Health Group HMO |
$6,187.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,599.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,177.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,692.15
|
| Rate for Payer: PHCS Commercial |
$7,919.52
|
| Rate for Payer: United Healthcare All Payer |
$7,259.56
|
|
|
ORIF W/INTRA BIP MM CU 4TH MET
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102794
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.67 |
| Max. Negotiated Rate |
$310.30 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Anthem Medicaid |
$32.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: First Health Commercial |
$90.25
|
| Rate for Payer: Humana Commercial |
$80.75
|
| Rate for Payer: Humana KY Medicaid |
$32.67
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$33.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.60
|
| Rate for Payer: Ohio Health Group HMO |
$71.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.55
|
| Rate for Payer: PHCS Commercial |
$91.20
|
| Rate for Payer: United Healthcare All Payer |
$83.60
|
|
|
ORIF W/INTRA BIP MM CU 4TH MET
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102794
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$57.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.50
|
| Rate for Payer: UHCCP Medicaid |
$33.25
|
|
|
ORIF W/INTRA BIP MM CU 4TH MET
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102794
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.10
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: First Health Commercial |
$90.25
|
| Rate for Payer: Humana Commercial |
$80.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.60
|
| Rate for Payer: Ohio Health Group HMO |
$71.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.55
|
| Rate for Payer: PHCS Commercial |
$91.20
|
| Rate for Payer: United Healthcare All Payer |
$83.60
|
|
|
OR LEVEL 1 PER 15 MIN
|
Facility
|
OP
|
$1,279.00
|
|
| Hospital Charge Code |
36001081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$383.70 |
| Max. Negotiated Rate |
$1,227.84 |
| Rate for Payer: Aetna Commercial |
$984.83
|
| Rate for Payer: Anthem Medicaid |
$439.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$997.62
|
| Rate for Payer: Cash Price |
$639.50
|
| Rate for Payer: Cigna Commercial |
$1,061.57
|
| Rate for Payer: First Health Commercial |
$1,215.05
|
| Rate for Payer: Humana Commercial |
$1,087.15
|
| Rate for Payer: Humana KY Medicaid |
$439.85
|
| Rate for Payer: Kentucky WC Medicaid |
$444.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$943.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$448.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,125.52
|
| Rate for Payer: Ohio Health Group HMO |
$959.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,023.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,112.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$882.51
|
| Rate for Payer: PHCS Commercial |
$1,227.84
|
| Rate for Payer: United Healthcare All Payer |
$1,125.52
|
|
|
OR LEVEL 1 PER 15 MIN
|
Facility
|
IP
|
$1,279.00
|
|
| Hospital Charge Code |
36001081
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$383.70 |
| Max. Negotiated Rate |
$1,227.84 |
| Rate for Payer: Aetna Commercial |
$984.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$997.62
|
| Rate for Payer: Cash Price |
$639.50
|
| Rate for Payer: Cigna Commercial |
$1,061.57
|
| Rate for Payer: First Health Commercial |
$1,215.05
|
| Rate for Payer: Humana Commercial |
$1,087.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$943.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,125.52
|
| Rate for Payer: Ohio Health Group HMO |
$959.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,023.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,112.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$882.51
|
| Rate for Payer: PHCS Commercial |
$1,227.84
|
| Rate for Payer: United Healthcare All Payer |
$1,125.52
|
|
|
OR LEVEL 2 PER 15 MIN
|
Facility
|
IP
|
$2,915.00
|
|
| Hospital Charge Code |
36001082
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$874.50 |
| Max. Negotiated Rate |
$2,798.40 |
| Rate for Payer: Aetna Commercial |
$2,244.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,273.70
|
| Rate for Payer: Cash Price |
$1,457.50
|
| Rate for Payer: Cigna Commercial |
$2,419.45
|
| Rate for Payer: First Health Commercial |
$2,769.25
|
| Rate for Payer: Humana Commercial |
$2,477.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,390.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$874.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,565.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,186.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,536.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,011.35
|
| Rate for Payer: PHCS Commercial |
$2,798.40
|
| Rate for Payer: United Healthcare All Payer |
$2,565.20
|
|
|
OR LEVEL 2 PER 15 MIN
|
Facility
|
OP
|
$2,915.00
|
|
| Hospital Charge Code |
36001082
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$874.50 |
| Max. Negotiated Rate |
$2,798.40 |
| Rate for Payer: Aetna Commercial |
$2,244.55
|
| Rate for Payer: Anthem Medicaid |
$1,002.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,273.70
|
| Rate for Payer: Cash Price |
$1,457.50
|
| Rate for Payer: Cigna Commercial |
$2,419.45
|
| Rate for Payer: First Health Commercial |
$2,769.25
|
| Rate for Payer: Humana Commercial |
$2,477.75
|
| Rate for Payer: Humana KY Medicaid |
$1,002.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,012.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,390.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$874.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,022.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,565.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,186.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,536.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,011.35
|
| Rate for Payer: PHCS Commercial |
$2,798.40
|
| Rate for Payer: United Healthcare All Payer |
$2,565.20
|
|
|
OR LEVEL 3 PER 15 MIN
|
Facility
|
OP
|
$4,254.00
|
|
| Hospital Charge Code |
36001083
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.20 |
| Max. Negotiated Rate |
$4,083.84 |
| Rate for Payer: Aetna Commercial |
$3,275.58
|
| Rate for Payer: Anthem Medicaid |
$1,462.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,318.12
|
| Rate for Payer: Cash Price |
$2,127.00
|
| Rate for Payer: Cigna Commercial |
$3,530.82
|
| Rate for Payer: First Health Commercial |
$4,041.30
|
| Rate for Payer: Humana Commercial |
$3,615.90
|
| Rate for Payer: Humana KY Medicaid |
$1,462.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,477.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,488.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,139.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,276.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,492.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,743.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,700.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,935.26
|
| Rate for Payer: PHCS Commercial |
$4,083.84
|
| Rate for Payer: United Healthcare All Payer |
$3,743.52
|
|
|
OR LEVEL 3 PER 15 MIN
|
Facility
|
IP
|
$4,254.00
|
|
| Hospital Charge Code |
36001083
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,276.20 |
| Max. Negotiated Rate |
$4,083.84 |
| Rate for Payer: Aetna Commercial |
$3,275.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,318.12
|
| Rate for Payer: Cash Price |
$2,127.00
|
| Rate for Payer: Cigna Commercial |
$3,530.82
|
| Rate for Payer: First Health Commercial |
$4,041.30
|
| Rate for Payer: Humana Commercial |
$3,615.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,488.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,139.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,276.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,743.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,700.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,935.26
|
| Rate for Payer: PHCS Commercial |
$4,083.84
|
| Rate for Payer: United Healthcare All Payer |
$3,743.52
|
|
|
OR LEVEL 4 PER 15 MIN
|
Facility
|
IP
|
$4,542.00
|
|
| Hospital Charge Code |
36001084
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,362.60 |
| Max. Negotiated Rate |
$4,360.32 |
| Rate for Payer: Aetna Commercial |
$3,497.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,542.76
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,769.86
|
| Rate for Payer: First Health Commercial |
$4,314.90
|
| Rate for Payer: Humana Commercial |
$3,860.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,996.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,633.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,133.98
|
| Rate for Payer: PHCS Commercial |
$4,360.32
|
| Rate for Payer: United Healthcare All Payer |
$3,996.96
|
|
|
OR LEVEL 4 PER 15 MIN
|
Facility
|
OP
|
$4,542.00
|
|
| Hospital Charge Code |
36001084
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,362.60 |
| Max. Negotiated Rate |
$4,360.32 |
| Rate for Payer: Aetna Commercial |
$3,497.34
|
| Rate for Payer: Anthem Medicaid |
$1,561.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,542.76
|
| Rate for Payer: Cash Price |
$2,271.00
|
| Rate for Payer: Cigna Commercial |
$3,769.86
|
| Rate for Payer: First Health Commercial |
$4,314.90
|
| Rate for Payer: Humana Commercial |
$3,860.70
|
| Rate for Payer: Humana KY Medicaid |
$1,561.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,577.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,996.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,633.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,133.98
|
| Rate for Payer: PHCS Commercial |
$4,360.32
|
| Rate for Payer: United Healthcare All Payer |
$3,996.96
|
|
|
OR LEVEL 5 PER 15 MIN
|
Facility
|
OP
|
$7,566.00
|
|
| Hospital Charge Code |
36001085
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,269.80 |
| Max. Negotiated Rate |
$7,263.36 |
| Rate for Payer: Aetna Commercial |
$5,825.82
|
| Rate for Payer: Anthem Medicaid |
$2,601.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,901.48
|
| Rate for Payer: Cash Price |
$3,783.00
|
| Rate for Payer: Cigna Commercial |
$6,279.78
|
| Rate for Payer: First Health Commercial |
$7,187.70
|
| Rate for Payer: Humana Commercial |
$6,431.10
|
| Rate for Payer: Humana KY Medicaid |
$2,601.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,628.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,204.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,583.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,269.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,654.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,658.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,674.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,052.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,582.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,220.54
|
| Rate for Payer: PHCS Commercial |
$7,263.36
|
| Rate for Payer: United Healthcare All Payer |
$6,658.08
|
|
|
OR LEVEL 5 PER 15 MIN
|
Facility
|
IP
|
$7,566.00
|
|
| Hospital Charge Code |
36001085
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,269.80 |
| Max. Negotiated Rate |
$7,263.36 |
| Rate for Payer: Aetna Commercial |
$5,825.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,901.48
|
| Rate for Payer: Cash Price |
$3,783.00
|
| Rate for Payer: Cigna Commercial |
$6,279.78
|
| Rate for Payer: First Health Commercial |
$7,187.70
|
| Rate for Payer: Humana Commercial |
$6,431.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,204.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,583.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,269.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,658.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,674.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,052.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,582.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,220.54
|
| Rate for Payer: PHCS Commercial |
$7,263.36
|
| Rate for Payer: United Healthcare All Payer |
$6,658.08
|
|
|
ORTHO/PROSMAN +/-TRAINSUB15MIN
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 97763
|
| Hospital Charge Code |
43000033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$18.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$18.91
|
| Rate for Payer: Kentucky WC Medicaid |
$19.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
ORTHO/PROSMAN +/-TRAINSUB15MIN
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 97763
|
| Hospital Charge Code |
43000033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.90
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.95
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
ORTHOTIC FIT/TRAINING 15 MIN
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
43000031
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.70 |
| Max. Negotiated Rate |
$85.44 |
| Rate for Payer: Aetna Commercial |
$68.53
|
| Rate for Payer: Anthem Medicaid |
$30.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.42
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$73.87
|
| Rate for Payer: First Health Commercial |
$84.55
|
| Rate for Payer: Humana Commercial |
$75.65
|
| Rate for Payer: Humana KY Medicaid |
$30.61
|
| Rate for Payer: Kentucky WC Medicaid |
$30.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.32
|
| Rate for Payer: Ohio Health Group HMO |
$66.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.41
|
| Rate for Payer: PHCS Commercial |
$85.44
|
| Rate for Payer: United Healthcare All Payer |
$78.32
|
|
|
ORTHOTIC FIT/TRAINING 15 MIN
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
43000031
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.70 |
| Max. Negotiated Rate |
$85.44 |
| Rate for Payer: Aetna Commercial |
$68.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.42
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$73.87
|
| Rate for Payer: First Health Commercial |
$84.55
|
| Rate for Payer: Humana Commercial |
$75.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.32
|
| Rate for Payer: Ohio Health Group HMO |
$66.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.41
|
| Rate for Payer: PHCS Commercial |
$85.44
|
| Rate for Payer: United Healthcare All Payer |
$78.32
|
|
|
ORTHOTIC FIT TRAINING 15MIN
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
42000037
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$82.56 |
| Rate for Payer: Aetna Commercial |
$66.22
|
| Rate for Payer: Anthem Medicaid |
$29.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.08
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$71.38
|
| Rate for Payer: First Health Commercial |
$81.70
|
| Rate for Payer: Humana Commercial |
$73.10
|
| Rate for Payer: Humana KY Medicaid |
$29.58
|
| Rate for Payer: Kentucky WC Medicaid |
$29.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.68
|
| Rate for Payer: Ohio Health Group HMO |
$64.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.34
|
| Rate for Payer: PHCS Commercial |
$82.56
|
| Rate for Payer: United Healthcare All Payer |
$75.68
|
|
|
ORTHOTIC FIT TRAINING 15MIN
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
42000037
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$82.56 |
| Rate for Payer: Aetna Commercial |
$66.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.08
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$71.38
|
| Rate for Payer: First Health Commercial |
$81.70
|
| Rate for Payer: Humana Commercial |
$73.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.68
|
| Rate for Payer: Ohio Health Group HMO |
$64.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.34
|
| Rate for Payer: PHCS Commercial |
$82.56
|
| Rate for Payer: United Healthcare All Payer |
$75.68
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
IP
|
$2,605.10
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
63600169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$781.53 |
| Max. Negotiated Rate |
$2,500.90 |
| Rate for Payer: Aetna Commercial |
$2,005.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,031.98
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cigna Commercial |
$2,162.23
|
| Rate for Payer: First Health Commercial |
$2,474.84
|
| Rate for Payer: Humana Commercial |
$2,214.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,136.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,922.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$781.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,292.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,953.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,084.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,266.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,797.52
|
| Rate for Payer: PHCS Commercial |
$2,500.90
|
| Rate for Payer: United Healthcare All Payer |
$2,292.49
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Professional
|
Both
|
$2,605.10
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
63600169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,563.06 |
| Rate for Payer: Aetna Commercial |
$203.45
|
| Rate for Payer: Ambetter Exchange |
$97.70
|
| Rate for Payer: Anthem Medicaid |
$225.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$97.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$97.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$117.24
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$225.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$97.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$229.50
|
| Rate for Payer: Molina Healthcare Passport |
$225.00
|
| Rate for Payer: Multiplan PHCS |
$1,563.06
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$127.01
|
| Rate for Payer: UHCCP Medicaid |
$911.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$227.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$97.70
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
IP
|
$2,605.10
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
636T0169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$781.53 |
| Max. Negotiated Rate |
$2,500.90 |
| Rate for Payer: Aetna Commercial |
$2,005.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,031.98
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cigna Commercial |
$2,162.23
|
| Rate for Payer: First Health Commercial |
$2,474.84
|
| Rate for Payer: Humana Commercial |
$2,214.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,136.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,922.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$781.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,292.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,953.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,084.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,266.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,797.52
|
| Rate for Payer: PHCS Commercial |
$2,500.90
|
| Rate for Payer: United Healthcare All Payer |
$2,292.49
|
|
