|
RENVELA (20mg)800MG TABLET
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
HCPCS J0601
|
| Hospital Charge Code |
25001306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RENVELA (20mg)800MG TABLET
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
HCPCS J0601
|
| Hospital Charge Code |
25001306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RENVELA (20mg)PWDR PACKET
|
Facility
|
IP
|
$34.85
|
|
|
Service Code
|
HCPCS J0602
|
| Hospital Charge Code |
25003404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$33.46 |
| Rate for Payer: Aetna Commercial |
$26.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.18
|
| Rate for Payer: Cash Price |
$17.42
|
| Rate for Payer: Cigna Commercial |
$28.93
|
| Rate for Payer: First Health Commercial |
$33.11
|
| Rate for Payer: Humana Commercial |
$29.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.05
|
| Rate for Payer: PHCS Commercial |
$33.46
|
| Rate for Payer: United Healthcare All Payer |
$30.67
|
|
|
RENVELA (20mg)PWDR PACKET
|
Facility
|
OP
|
$34.85
|
|
|
Service Code
|
HCPCS J0602
|
| Hospital Charge Code |
25003404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$33.46 |
| Rate for Payer: Aetna Commercial |
$26.83
|
| Rate for Payer: Anthem Medicaid |
$11.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.18
|
| Rate for Payer: Cash Price |
$17.42
|
| Rate for Payer: Cigna Commercial |
$28.93
|
| Rate for Payer: First Health Commercial |
$33.11
|
| Rate for Payer: Humana Commercial |
$29.62
|
| Rate for Payer: Humana KY Medicaid |
$11.98
|
| Rate for Payer: Kentucky WC Medicaid |
$12.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.67
|
| Rate for Payer: Ohio Health Group HMO |
$26.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.05
|
| Rate for Payer: PHCS Commercial |
$33.46
|
| Rate for Payer: United Healthcare All Payer |
$30.67
|
|
|
REOPEN FALLOPIAN TUBE
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
HCPCS 58350
|
| Hospital Charge Code |
76102224
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.72 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem Medicaid |
$142.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Humana KY Medicaid |
$142.72
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Kentucky WC Medicaid |
$144.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$361.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.35
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
REOPEN FALLOPIAN TUBE
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS 58350
|
| Hospital Charge Code |
76102224
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$361.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.35
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
REOPEN FALLOPIAN TUBE
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 58350
|
| Hospital Charge Code |
76102224
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna Commercial |
$116.17
|
| Rate for Payer: Ambetter Exchange |
$87.71
|
| Rate for Payer: Anthem Medicaid |
$50.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.25
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$114.81
|
| Rate for Payer: Healthspan PPO |
$137.36
|
| Rate for Payer: Humana Medicaid |
$50.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$51.57
|
| Rate for Payer: Molina Healthcare Passport |
$50.56
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$114.02
|
| Rate for Payer: UHCCP Medicaid |
$145.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.71
|
|
|
REOPEN FALLOPIAN TUBE(P
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 58350
|
| Hospital Charge Code |
761P2224
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna Commercial |
$116.17
|
| Rate for Payer: Ambetter Exchange |
$87.71
|
| Rate for Payer: Anthem Medicaid |
$50.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.25
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$114.81
|
| Rate for Payer: Healthspan PPO |
$137.36
|
| Rate for Payer: Humana Medicaid |
$50.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$51.57
|
| Rate for Payer: Molina Healthcare Passport |
$50.56
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$114.02
|
| Rate for Payer: UHCCP Medicaid |
$145.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.71
|
|
|
REOPENING OF ABDOMEN
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49002
|
| Hospital Charge Code |
76101975
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
REOPENING OF ABDOMEN
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49002
|
| Hospital Charge Code |
76101975
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$467.50 |
| Max. Negotiated Rate |
$1,445.76 |
| Rate for Payer: Aetna Commercial |
$1,445.76
|
| Rate for Payer: Ambetter Exchange |
$993.20
|
| Rate for Payer: Anthem Medicaid |
$467.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$993.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$993.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,191.84
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,305.40
|
| Rate for Payer: Healthspan PPO |
$1,219.24
|
| Rate for Payer: Humana Medicaid |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,326.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$993.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$476.85
|
| Rate for Payer: Molina Healthcare Passport |
$467.50
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,291.16
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$472.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$993.20
|
|
|
REOPENING OF ABDOMEN
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49002
|
| Hospital Charge Code |
76101975
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
REOPENING OF ABDOMEN(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49002
|
| Hospital Charge Code |
761P1975
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$467.50 |
| Max. Negotiated Rate |
$1,445.76 |
| Rate for Payer: Aetna Commercial |
$1,445.76
|
| Rate for Payer: Ambetter Exchange |
$993.20
|
| Rate for Payer: Anthem Medicaid |
$467.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$993.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$993.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,191.84
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,305.40
|
| Rate for Payer: Healthspan PPO |
$1,219.24
|
| Rate for Payer: Humana Medicaid |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,326.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$993.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$476.85
|
| Rate for Payer: Molina Healthcare Passport |
$467.50
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,291.16
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$472.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$993.20
|
|
|
REOPERATION BYPASS GRAFT
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS 35700
|
| Hospital Charge Code |
76101419
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$345.60 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$280.80
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$298.80
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: Humana Commercial |
$306.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$295.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$265.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$316.80
|
| Rate for Payer: Ohio Health Group HMO |
$270.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$313.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.40
|
| Rate for Payer: PHCS Commercial |
$345.60
|
| Rate for Payer: United Healthcare All Payer |
$316.80
|
|
|
REOPERATION BYPASS GRAFT
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS 35700
|
| Hospital Charge Code |
76101419
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$345.60 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Anthem Medicaid |
$123.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$280.80
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$298.80
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: Humana Commercial |
$306.00
|
| Rate for Payer: Humana KY Medicaid |
$123.80
|
| Rate for Payer: Kentucky WC Medicaid |
$125.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$295.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$265.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$126.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$316.80
|
| Rate for Payer: Ohio Health Group HMO |
$270.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$313.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.40
|
| Rate for Payer: PHCS Commercial |
$345.60
|
| Rate for Payer: United Healthcare All Payer |
$316.80
|
|
|
REOPERATION BYPASS GRAFT
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
HCPCS 35700
|
| Hospital Charge Code |
76101419
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$276.75 |
| Rate for Payer: Aetna Commercial |
$276.75
|
| Rate for Payer: Ambetter Exchange |
$142.41
|
| Rate for Payer: Anthem Medicaid |
$142.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$142.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$170.89
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$263.02
|
| Rate for Payer: Healthspan PPO |
$272.10
|
| Rate for Payer: Humana Medicaid |
$142.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$211.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$142.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$145.66
|
| Rate for Payer: Molina Healthcare Passport |
$142.80
|
| Rate for Payer: Multiplan PHCS |
$216.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.13
|
| Rate for Payer: UHCCP Medicaid |
$126.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$142.41
|
|
|
REOPERATION BYPASS GRAFT(P
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
HCPCS 35700
|
| Hospital Charge Code |
761P1419
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$276.75 |
| Rate for Payer: Aetna Commercial |
$276.75
|
| Rate for Payer: Ambetter Exchange |
$142.41
|
| Rate for Payer: Anthem Medicaid |
$142.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$142.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$170.89
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$263.02
|
| Rate for Payer: Healthspan PPO |
$272.10
|
| Rate for Payer: Humana Medicaid |
$142.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$211.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$142.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$145.66
|
| Rate for Payer: Molina Healthcare Passport |
$142.80
|
| Rate for Payer: Multiplan PHCS |
$216.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.13
|
| Rate for Payer: UHCCP Medicaid |
$126.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$142.41
|
|
|
REOPERATION - CAROTID
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 35390
|
| Hospital Charge Code |
76101390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
REOPERATION - CAROTID
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 35390
|
| Hospital Charge Code |
76101390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.88 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$288.04
|
| Rate for Payer: Ambetter Exchange |
$149.62
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$149.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$149.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$179.54
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$273.03
|
| Rate for Payer: Healthspan PPO |
$283.20
|
| Rate for Payer: Humana Medicaid |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$149.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.84
|
| Rate for Payer: Molina Healthcare Passport |
$147.88
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$194.51
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$149.62
|
|
|
REOPERATION - CAROTID
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 35390
|
| Hospital Charge Code |
76101390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.31
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
REOPERATION - CAROTID(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 35390
|
| Hospital Charge Code |
761P1390
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.88 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$288.04
|
| Rate for Payer: Ambetter Exchange |
$149.62
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$149.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$149.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$179.54
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$273.03
|
| Rate for Payer: Healthspan PPO |
$283.20
|
| Rate for Payer: Humana Medicaid |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$149.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.84
|
| Rate for Payer: Molina Healthcare Passport |
$147.88
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$194.51
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$149.62
|
|
|
REPAIR 2 DIS LIG ANKLE COLTRL
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS 27698
|
| Hospital Charge Code |
76100915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
REPAIR 2 DIS LIG ANKLE COLTRL
|
Professional
|
Both
|
$2,060.00
|
|
|
Service Code
|
HCPCS 27698
|
| Hospital Charge Code |
76100915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.50 |
| Max. Negotiated Rate |
$1,236.00 |
| Rate for Payer: Aetna Commercial |
$983.77
|
| Rate for Payer: Ambetter Exchange |
$607.50
|
| Rate for Payer: Anthem Medicaid |
$609.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$607.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$607.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$729.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,081.76
|
| Rate for Payer: Healthspan PPO |
$891.08
|
| Rate for Payer: Humana Medicaid |
$609.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$607.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$622.10
|
| Rate for Payer: Molina Healthcare Passport |
$609.90
|
| Rate for Payer: Multiplan PHCS |
$1,236.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$789.75
|
| Rate for Payer: UHCCP Medicaid |
$721.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$616.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$607.50
|
|
|
REPAIR 2 DIS LIG ANKLE COLTRL
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS 27698
|
| Hospital Charge Code |
76100915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$708.43 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem Medicaid |
$708.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Humana KY Medicaid |
$708.43
|
| Rate for Payer: Humana Medicare Advantage |
$6,600.66
|
| Rate for Payer: Kentucky WC Medicaid |
$715.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,920.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
REPAIR 2 DIS LIG ANKLE COLTR(P
|
Professional
|
Both
|
$2,060.00
|
|
|
Service Code
|
HCPCS 27698
|
| Hospital Charge Code |
761P0915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.50 |
| Max. Negotiated Rate |
$1,236.00 |
| Rate for Payer: Aetna Commercial |
$983.77
|
| Rate for Payer: Ambetter Exchange |
$607.50
|
| Rate for Payer: Anthem Medicaid |
$609.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$607.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$607.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$729.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,081.76
|
| Rate for Payer: Healthspan PPO |
$891.08
|
| Rate for Payer: Humana Medicaid |
$609.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$607.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$622.10
|
| Rate for Payer: Molina Healthcare Passport |
$609.90
|
| Rate for Payer: Multiplan PHCS |
$1,236.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$789.75
|
| Rate for Payer: UHCCP Medicaid |
$721.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$616.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$607.50
|
|
|
REPAIR ACHILLES TENDON
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27650
|
| Hospital Charge Code |
76100906
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$490.00 |
| Max. Negotiated Rate |
$1,148.57 |
| Rate for Payer: Aetna Commercial |
$1,002.02
|
| Rate for Payer: Ambetter Exchange |
$626.19
|
| Rate for Payer: Anthem Medicaid |
$541.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$626.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$626.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$751.43
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,148.57
|
| Rate for Payer: Healthspan PPO |
$907.61
|
| Rate for Payer: Humana Medicaid |
$541.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$827.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$626.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$626.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$552.10
|
| Rate for Payer: Molina Healthcare Passport |
$541.27
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$814.05
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$546.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$626.19
|
|
