|
REPR INTEMED WOUNDS FACE 2.5 C
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12051
|
| Hospital Charge Code |
761T0143
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPR INTERMED FACE 2.6-5.0 CM
|
Professional
|
Both
|
$949.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
76100144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$949.00 |
| Rate for Payer: Aetna Commercial |
$298.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.53
|
| Rate for Payer: Anthem Medicaid |
$102.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$949.00
|
| Rate for Payer: Cash Price |
$474.50
|
| Rate for Payer: Cash Price |
$474.50
|
| Rate for Payer: Cigna Commercial |
$359.71
|
| Rate for Payer: Healthspan PPO |
$329.83
|
| Rate for Payer: Humana Medicaid |
$102.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.99
|
| Rate for Payer: Molina Healthcare Passport |
$102.93
|
| Rate for Payer: Multiplan PHCS |
$569.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$664.30
|
| Rate for Payer: UHCCP Medicaid |
$105.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.96
|
|
|
REPR INTERMED FACE 2.6-5.0 CM
|
Facility
|
OP
|
$949.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
76100144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.37 |
| Max. Negotiated Rate |
$911.04 |
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Aetna Commercial |
$730.73
|
| Rate for Payer: Anthem Medicaid |
$326.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$740.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$474.50
|
| Rate for Payer: Cash Price |
$474.50
|
| Rate for Payer: Cigna Commercial |
$787.67
|
| Rate for Payer: First Health Commercial |
$901.55
|
| Rate for Payer: Humana Commercial |
$806.65
|
| Rate for Payer: Humana KY Medicaid |
$326.36
|
| Rate for Payer: Kentucky WC Medicaid |
$329.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$778.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$700.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$835.12
|
| Rate for Payer: Ohio Health Group HMO |
$711.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.19
|
| Rate for Payer: PHCS Commercial |
$911.04
|
| Rate for Payer: United Healthcare All Payer |
$835.12
|
|
|
REPR INTERMED FACE 2.6-5.0 CM
|
Facility
|
IP
|
$949.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
76100144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.37 |
| Max. Negotiated Rate |
$911.04 |
| Rate for Payer: Aetna Commercial |
$730.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$740.22
|
| Rate for Payer: Cash Price |
$474.50
|
| Rate for Payer: Cigna Commercial |
$787.67
|
| Rate for Payer: First Health Commercial |
$901.55
|
| Rate for Payer: Humana Commercial |
$806.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$778.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$700.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$835.12
|
| Rate for Payer: Ohio Health Group HMO |
$711.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.19
|
| Rate for Payer: PHCS Commercial |
$911.04
|
| Rate for Payer: United Healthcare All Payer |
$835.12
|
|
|
REPR INTERMED FACE 2.6-5.0 CM
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
45000066
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPR INTERMED FACE 2.6-5.0 CM
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
45000066
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPR INTERMED FACE 2.6-5.0 C(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
761P0144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$298.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.53
|
| Rate for Payer: Anthem Medicaid |
$102.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$359.71
|
| Rate for Payer: Healthspan PPO |
$329.83
|
| Rate for Payer: Humana Medicaid |
$102.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.99
|
| Rate for Payer: Molina Healthcare Passport |
$102.93
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$105.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.96
|
|
|
REPR INTERMED FACE 2.6-5.0 C(T
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
761T0144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPR INTERMED FACE 2.6-5.0 C(T
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12052
|
| Hospital Charge Code |
761T0144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPR LAC 2.5<FLRMOUTPOST2/3TNG
|
Facility
|
IP
|
$292.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
76101662
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$224.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.76
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cigna Commercial |
$242.36
|
| Rate for Payer: First Health Commercial |
$277.40
|
| Rate for Payer: Humana Commercial |
$248.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.96
|
| Rate for Payer: Ohio Health Group HMO |
$219.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.52
|
| Rate for Payer: PHCS Commercial |
$280.32
|
| Rate for Payer: United Healthcare All Payer |
$256.96
|
|
|
REPR LAC 2.5<FLRMOUTPOST2/3TNG
|
Facility
|
OP
|
$292.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
76101662
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$224.84
|
| Rate for Payer: Anthem Medicaid |
$100.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$285.16
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cigna Commercial |
$242.36
|
| Rate for Payer: First Health Commercial |
$277.40
|
| Rate for Payer: Humana Commercial |
$248.20
|
| Rate for Payer: Humana KY Medicaid |
$100.42
|
| Rate for Payer: Humana Medicare Advantage |
$211.23
|
| Rate for Payer: Kentucky WC Medicaid |
$101.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.96
|
| Rate for Payer: Ohio Health Group HMO |
$219.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.52
|
| Rate for Payer: PHCS Commercial |
$280.32
|
| Rate for Payer: United Healthcare All Payer |
$256.96
|
|
|
REPR LAC 2.5<FLRMOUTPOST2/3TNG
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
45000253
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$39.52 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.24
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
REPR LAC 2.5<FLRMOUTPOST2/3TNG
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
45000253
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$39.52 |
| Max. Negotiated Rate |
$295.72 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem Medicaid |
$104.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$285.16
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Humana KY Medicaid |
$104.55
|
| Rate for Payer: Humana Medicare Advantage |
$211.23
|
| Rate for Payer: Kentucky WC Medicaid |
$105.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.24
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
REPR LAC VESTIBLEMOUT>2.5 COMP
|
Facility
|
IP
|
$633.00
|
|
|
Service Code
|
HCPCS 40831
|
| Hospital Charge Code |
76101642
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.29 |
| Max. Negotiated Rate |
$607.68 |
| Rate for Payer: Aetna Commercial |
$487.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$493.74
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cigna Commercial |
$525.39
|
| Rate for Payer: First Health Commercial |
$601.35
|
| Rate for Payer: Humana Commercial |
$538.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.04
|
| Rate for Payer: Ohio Health Group HMO |
$474.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$196.23
|
| Rate for Payer: PHCS Commercial |
$607.68
|
| Rate for Payer: United Healthcare All Payer |
$557.04
|
|
|
REPR LAC VESTIBLEMOUT>2.5 COMP
|
Facility
|
OP
|
$633.00
|
|
|
Service Code
|
HCPCS 40831
|
| Hospital Charge Code |
76101642
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.29 |
| Max. Negotiated Rate |
$666.11 |
| Rate for Payer: Aetna Commercial |
$487.41
|
| Rate for Payer: Anthem Medicaid |
$217.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$493.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cigna Commercial |
$525.39
|
| Rate for Payer: First Health Commercial |
$601.35
|
| Rate for Payer: Humana Commercial |
$538.05
|
| Rate for Payer: Humana KY Medicaid |
$217.69
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$219.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$222.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.04
|
| Rate for Payer: Ohio Health Group HMO |
$474.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$196.23
|
| Rate for Payer: PHCS Commercial |
$607.68
|
| Rate for Payer: United Healthcare All Payer |
$557.04
|
|
|
REPR LAC VESTIBLEMOUT>2.5 COMP
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 40831
|
| Hospital Charge Code |
45000250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPR LAC VESTIBLEMOUT>2.5 COMP
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 40831
|
| Hospital Charge Code |
45000250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$666.11 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPR OF ANAL FISTULA W/GLUE
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 46706
|
| Hospital Charge Code |
76101933
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REPR OF ANAL FISTULA W/GLUE
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 46706
|
| Hospital Charge Code |
76101933
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.07 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$237.21
|
| Rate for Payer: Anthem Medicaid |
$105.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$215.67
|
| Rate for Payer: Healthspan PPO |
$200.04
|
| Rate for Payer: Humana Medicaid |
$105.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$209.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.17
|
| Rate for Payer: Molina Healthcare Passport |
$105.07
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.12
|
|
|
REPR OF ANAL FISTULA W/GLUE
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 46706
|
| Hospital Charge Code |
76101933
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$3,399.27 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,428.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,399.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,277.87
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$2,428.05
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,913.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REPR OF ANAL FISTULA W/GLUE(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 46706
|
| Hospital Charge Code |
761P1933
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.07 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$237.21
|
| Rate for Payer: Anthem Medicaid |
$105.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$215.67
|
| Rate for Payer: Healthspan PPO |
$200.04
|
| Rate for Payer: Humana Medicaid |
$105.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$209.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.17
|
| Rate for Payer: Molina Healthcare Passport |
$105.07
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.12
|
|
|
REQUIP (ROPINIROLE) 0.25MG TAB
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 60687057701
|
| Hospital Charge Code |
25001307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| 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 |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
REQUIP (ROPINIROLE) 0.25MG TAB
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 60687057701
|
| Hospital Charge Code |
25001307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| 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 |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
REQUIP (ROPINIROLE) 0.5MG TAB
|
Facility
|
IP
|
$4.64
|
|
|
Service Code
|
NDC 50268074215
|
| Hospital Charge Code |
25001308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
|
REQUIP (ROPINIROLE) 0.5MG TAB
|
Facility
|
OP
|
$4.64
|
|
|
Service Code
|
NDC 50268074215
|
| Hospital Charge Code |
25001308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.45 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.85
|
| Rate for Payer: First Health Commercial |
$4.41
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.08
|
| Rate for Payer: Ohio Health Group HMO |
$3.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.45
|
| Rate for Payer: United Healthcare All Payer |
$4.08
|
|
