|
BI-METRIC FEMORAL COMP 8*120
|
Facility
|
IP
|
$22,006.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,860.79 |
| Max. Negotiated Rate |
$21,125.86 |
| Rate for Payer: Aetna Commercial |
$16,944.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,164.76
|
| Rate for Payer: Cash Price |
$11,003.05
|
| Rate for Payer: Cigna Commercial |
$18,265.06
|
| Rate for Payer: First Health Commercial |
$20,905.80
|
| Rate for Payer: Humana Commercial |
$18,705.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,045.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,240.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,601.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,365.37
|
| Rate for Payer: Ohio Health Group HMO |
$16,504.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,401.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,860.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,821.89
|
| Rate for Payer: PHCS Commercial |
$21,125.86
|
| Rate for Payer: United Healthcare All Payer |
$19,365.37
|
|
|
BINOCULAR MICROSCOPY
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 92504
|
| Hospital Charge Code |
47000048
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
BINOCULAR MICROSCOPY
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 92504
|
| Hospital Charge Code |
47000048
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
BINOCULAR MICROSCOPY(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 92504
|
| Hospital Charge Code |
470P0048
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$12.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$4.09
|
| Rate for Payer: Anthem Medicaid |
$9.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$39.13
|
| Rate for Payer: Healthspan PPO |
$34.05
|
| Rate for Payer: Humana Medicaid |
$9.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$9.44
|
| Rate for Payer: Molina Healthcare Passport |
$9.25
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$4.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$9.34
|
|
|
BINOCULAR MICROSCOPY(T
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS 92504
|
| Hospital Charge Code |
470T0048
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.54
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
BINOCULAR MICROSCOPY(T
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS 92504
|
| Hospital Charge Code |
470T0048
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$41.28 |
| Rate for Payer: Aetna Commercial |
$33.11
|
| Rate for Payer: Anthem Medicaid |
$14.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.54
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Cigna Commercial |
$35.69
|
| Rate for Payer: First Health Commercial |
$40.85
|
| Rate for Payer: Humana Commercial |
$36.55
|
| Rate for Payer: Humana KY Medicaid |
$14.79
|
| Rate for Payer: Kentucky WC Medicaid |
$14.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.84
|
| Rate for Payer: Ohio Health Group HMO |
$32.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.33
|
| Rate for Payer: PHCS Commercial |
$41.28
|
| Rate for Payer: United Healthcare All Payer |
$37.84
|
|
|
BIOCARTILAGE 1CC
|
Facility
|
IP
|
$5,630.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.90 |
| Max. Negotiated Rate |
$5,404.80 |
| Rate for Payer: Aetna Commercial |
$4,335.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,391.40
|
| Rate for Payer: Cash Price |
$2,815.00
|
| Rate for Payer: Cigna Commercial |
$4,672.90
|
| Rate for Payer: First Health Commercial |
$5,348.50
|
| Rate for Payer: Humana Commercial |
$4,785.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,616.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,689.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,954.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,126.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$731.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,745.30
|
| Rate for Payer: PHCS Commercial |
$5,404.80
|
| Rate for Payer: United Healthcare All Payer |
$4,954.40
|
|
|
BIOCARTILAGE 1CC
|
Facility
|
OP
|
$5,630.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.90 |
| Max. Negotiated Rate |
$5,404.80 |
| Rate for Payer: Aetna Commercial |
$4,335.10
|
| Rate for Payer: Anthem Medicaid |
$1,936.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,391.40
|
| Rate for Payer: Cash Price |
$2,815.00
|
| Rate for Payer: Cigna Commercial |
$4,672.90
|
| Rate for Payer: First Health Commercial |
$5,348.50
|
| Rate for Payer: Humana Commercial |
$4,785.50
|
| Rate for Payer: Humana KY Medicaid |
$1,936.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,955.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,616.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,689.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,954.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,126.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$731.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,745.30
|
| Rate for Payer: PHCS Commercial |
$5,404.80
|
| Rate for Payer: United Healthcare All Payer |
$4,954.40
|
|
|
BIOCARTILAGE KIT SMALL JOINT
|
Facility
|
OP
|
$2,207.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.98 |
| Max. Negotiated Rate |
$2,119.20 |
| Rate for Payer: Aetna Commercial |
$1,699.78
|
| Rate for Payer: Anthem Medicaid |
$759.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,721.85
|
| Rate for Payer: Cash Price |
$1,103.75
|
| Rate for Payer: Cigna Commercial |
$1,832.22
|
| Rate for Payer: First Health Commercial |
$2,097.12
|
| Rate for Payer: Humana Commercial |
$1,876.38
|
| Rate for Payer: Humana KY Medicaid |
$759.16
|
| Rate for Payer: Kentucky WC Medicaid |
$766.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,810.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,629.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$662.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$774.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,942.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,655.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$441.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$684.32
|
| Rate for Payer: PHCS Commercial |
$2,119.20
|
| Rate for Payer: United Healthcare All Payer |
$1,942.60
|
|
|
BIOCARTILAGE KIT SMALL JOINT
|
Facility
|
IP
|
$2,207.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$286.98 |
| Max. Negotiated Rate |
$2,119.20 |
| Rate for Payer: Aetna Commercial |
$1,699.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,721.85
|
| Rate for Payer: Cash Price |
$1,103.75
|
| Rate for Payer: Cigna Commercial |
$1,832.22
|
| Rate for Payer: First Health Commercial |
$2,097.12
|
| Rate for Payer: Humana Commercial |
$1,876.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,810.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,629.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$662.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,942.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,655.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$441.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$684.32
|
| Rate for Payer: PHCS Commercial |
$2,119.20
|
| Rate for Payer: United Healthcare All Payer |
$1,942.60
|
|
|
BIO COMP SWVL LCK ANCH 3.9*17*
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
BIO COMP SWVL LCK ANCH 3.9*17*
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
BIOCORNEUM SCAR CREAM 10G
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
22200204
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
BIOCORNEUM SCAR CREAM 20G
|
Professional
|
Both
|
$72.00
|
|
| Hospital Charge Code |
22200205
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$72.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Multiplan PHCS |
$43.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.40
|
| Rate for Payer: UHCCP Medicaid |
$25.20
|
|
|
BIOFEEDBACK MODALITY
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS 90901
|
| Hospital Charge Code |
42000001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
BIOFEEDBACK MODALITY
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS 90901
|
| Hospital Charge Code |
43000001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
BIOFEEDBACK MODALITY
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 90901
|
| Hospital Charge Code |
42000001
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
BIOFEEDBACK MODALITY
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 90901
|
| Hospital Charge Code |
43000001
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
BIOFLO MIDLINE 4.5FR
|
Facility
|
OP
|
$1,942.90
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.58 |
| Max. Negotiated Rate |
$1,865.18 |
| Rate for Payer: Aetna Commercial |
$1,496.03
|
| Rate for Payer: Anthem Medicaid |
$668.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,515.46
|
| Rate for Payer: Cash Price |
$971.45
|
| Rate for Payer: Cigna Commercial |
$1,612.61
|
| Rate for Payer: First Health Commercial |
$1,845.76
|
| Rate for Payer: Humana Commercial |
$1,651.46
|
| Rate for Payer: Humana KY Medicaid |
$668.16
|
| Rate for Payer: Kentucky WC Medicaid |
$674.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,593.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,433.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$582.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,709.75
|
| Rate for Payer: Ohio Health Group HMO |
$1,457.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$388.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.30
|
| Rate for Payer: PHCS Commercial |
$1,865.18
|
| Rate for Payer: United Healthcare All Payer |
$1,709.75
|
|
|
BIOFLO MIDLINE 4.5FR
|
Facility
|
IP
|
$1,942.90
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.58 |
| Max. Negotiated Rate |
$1,865.18 |
| Rate for Payer: Aetna Commercial |
$1,496.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,515.46
|
| Rate for Payer: Cash Price |
$971.45
|
| Rate for Payer: Cigna Commercial |
$1,612.61
|
| Rate for Payer: First Health Commercial |
$1,845.76
|
| Rate for Payer: Humana Commercial |
$1,651.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,593.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,433.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$582.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,709.75
|
| Rate for Payer: Ohio Health Group HMO |
$1,457.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$388.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.30
|
| Rate for Payer: PHCS Commercial |
$1,865.18
|
| Rate for Payer: United Healthcare All Payer |
$1,709.75
|
|
|
BIOFLO PORT 8FR 44-022
|
Facility
|
IP
|
$3,853.75
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$500.99 |
| Max. Negotiated Rate |
$3,699.60 |
| Rate for Payer: Aetna Commercial |
$2,967.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,005.92
|
| Rate for Payer: Cash Price |
$1,926.88
|
| Rate for Payer: Cigna Commercial |
$3,198.61
|
| Rate for Payer: First Health Commercial |
$3,661.06
|
| Rate for Payer: Humana Commercial |
$3,275.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,160.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,844.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,391.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,890.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$770.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$500.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,194.66
|
| Rate for Payer: PHCS Commercial |
$3,699.60
|
| Rate for Payer: United Healthcare All Payer |
$3,391.30
|
|
|
BIOFLO PORT 8FR 44-022
|
Facility
|
OP
|
$3,853.75
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$500.99 |
| Max. Negotiated Rate |
$3,699.60 |
| Rate for Payer: Aetna Commercial |
$2,967.39
|
| Rate for Payer: Anthem Medicaid |
$1,325.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,005.92
|
| Rate for Payer: Cash Price |
$1,926.88
|
| Rate for Payer: Cigna Commercial |
$3,198.61
|
| Rate for Payer: First Health Commercial |
$3,661.06
|
| Rate for Payer: Humana Commercial |
$3,275.69
|
| Rate for Payer: Humana KY Medicaid |
$1,325.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,338.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,160.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,844.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,351.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,391.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,890.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$770.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$500.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,194.66
|
| Rate for Payer: PHCS Commercial |
$3,699.60
|
| Rate for Payer: United Healthcare All Payer |
$3,391.30
|
|
|
BIOFLO PORT DUAL 8FR 44-028
|
Facility
|
IP
|
$8,023.15
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,043.01 |
| Max. Negotiated Rate |
$7,702.22 |
| Rate for Payer: Aetna Commercial |
$6,177.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,258.06
|
| Rate for Payer: Cash Price |
$4,011.57
|
| Rate for Payer: Cigna Commercial |
$6,659.21
|
| Rate for Payer: First Health Commercial |
$7,621.99
|
| Rate for Payer: Humana Commercial |
$6,819.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,578.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,921.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,406.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,060.37
|
| Rate for Payer: Ohio Health Group HMO |
$6,017.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,604.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,043.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,487.18
|
| Rate for Payer: PHCS Commercial |
$7,702.22
|
| Rate for Payer: United Healthcare All Payer |
$7,060.37
|
|
|
BIOFLO PORT DUAL 8FR 44-028
|
Facility
|
OP
|
$8,023.15
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,043.01 |
| Max. Negotiated Rate |
$7,702.22 |
| Rate for Payer: Aetna Commercial |
$6,177.83
|
| Rate for Payer: Anthem Medicaid |
$2,759.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,258.06
|
| Rate for Payer: Cash Price |
$4,011.57
|
| Rate for Payer: Cigna Commercial |
$6,659.21
|
| Rate for Payer: First Health Commercial |
$7,621.99
|
| Rate for Payer: Humana Commercial |
$6,819.68
|
| Rate for Payer: Humana KY Medicaid |
$2,759.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,787.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,578.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,921.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,406.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,814.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,060.37
|
| Rate for Payer: Ohio Health Group HMO |
$6,017.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,604.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,043.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,487.18
|
| Rate for Payer: PHCS Commercial |
$7,702.22
|
| Rate for Payer: United Healthcare All Payer |
$7,060.37
|
|
|
BIOFREEZE (3mL)
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 59316011511
|
| Hospital Charge Code |
25004097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| 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 |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
