|
SIGMOIDOSCOPY W/SUBMUC INJ
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS 45335
|
| Hospital Charge Code |
76101885
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$691.20 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$561.60
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$597.60
|
| Rate for Payer: First Health Commercial |
$684.00
|
| Rate for Payer: Humana Commercial |
$612.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$590.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$531.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$633.60
|
| Rate for Payer: Ohio Health Group HMO |
$540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.20
|
| Rate for Payer: PHCS Commercial |
$691.20
|
| Rate for Payer: United Healthcare All Payer |
$633.60
|
|
|
SIGMOIDOSCOPY W/SUBMUC INJ(P
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 45335
|
| Hospital Charge Code |
761P1885
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.66 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$137.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.79
|
| Rate for Payer: Anthem Medicaid |
$57.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$720.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$124.92
|
| Rate for Payer: Healthspan PPO |
$288.02
|
| Rate for Payer: Humana Medicaid |
$57.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.81
|
| Rate for Payer: Molina Healthcare Passport |
$57.66
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.00
|
| Rate for Payer: UHCCP Medicaid |
$70.13
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.24
|
|
|
SIGMOIDOSCOPY W/TUMR REMOVE
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 45338
|
| Hospital Charge Code |
76101887
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.87 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$214.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$120.87
|
| Rate for Payer: Anthem Medicaid |
$141.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$193.75
|
| Rate for Payer: Healthspan PPO |
$378.54
|
| Rate for Payer: Humana Medicaid |
$141.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$184.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.65
|
| Rate for Payer: Molina Healthcare Passport |
$141.81
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$126.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$143.23
|
|
|
SIGMOIDOSCOPY W/TUMR REMOVE
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 45338
|
| Hospital Charge Code |
76101887
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
SIGMOIDOSCOPY W/TUMR REMOVE
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 45338
|
| Hospital Charge Code |
76101887
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$1,428.66 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,020.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,428.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,377.63
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,020.47
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,224.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
SIGMOIDOSCOPY W/TUMR REMOVE(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 45338
|
| Hospital Charge Code |
761P1887
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.87 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$214.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$120.87
|
| Rate for Payer: Anthem Medicaid |
$141.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$193.75
|
| Rate for Payer: Healthspan PPO |
$378.54
|
| Rate for Payer: Humana Medicaid |
$141.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$184.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.65
|
| Rate for Payer: Molina Healthcare Passport |
$141.81
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$126.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$143.23
|
|
|
SIGMOID RESECTION HARTMANS
|
Facility
|
OP
|
$2,386.00
|
|
|
Service Code
|
HCPCS 44206
|
| Hospital Charge Code |
76101830
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$310.18 |
| Max. Negotiated Rate |
$2,290.56 |
| Rate for Payer: Aetna Commercial |
$1,837.22
|
| Rate for Payer: Anthem Medicaid |
$820.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,861.08
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cigna Commercial |
$1,980.38
|
| Rate for Payer: First Health Commercial |
$2,266.70
|
| Rate for Payer: Humana Commercial |
$2,028.10
|
| Rate for Payer: Humana KY Medicaid |
$820.55
|
| Rate for Payer: Kentucky WC Medicaid |
$828.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,956.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,760.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$715.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$837.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,099.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,789.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$477.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$739.66
|
| Rate for Payer: PHCS Commercial |
$2,290.56
|
| Rate for Payer: United Healthcare All Payer |
$2,099.68
|
|
|
SIGMOID RESECTION HARTMANS
|
Facility
|
IP
|
$2,386.00
|
|
|
Service Code
|
HCPCS 44206
|
| Hospital Charge Code |
76101830
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$310.18 |
| Max. Negotiated Rate |
$2,290.56 |
| Rate for Payer: Aetna Commercial |
$1,837.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,861.08
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cigna Commercial |
$1,980.38
|
| Rate for Payer: First Health Commercial |
$2,266.70
|
| Rate for Payer: Humana Commercial |
$2,028.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,956.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,760.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$715.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,099.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,789.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$477.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$739.66
|
| Rate for Payer: PHCS Commercial |
$2,290.56
|
| Rate for Payer: United Healthcare All Payer |
$2,099.68
|
|
|
SIGMOID RESECTION HARTMANS
|
Professional
|
Both
|
$2,386.00
|
|
|
Service Code
|
HCPCS 44206
|
| Hospital Charge Code |
76101830
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$835.10 |
| Max. Negotiated Rate |
$2,546.65 |
| Rate for Payer: Aetna Commercial |
$2,546.65
|
| Rate for Payer: Anthem Medicaid |
$1,117.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,386.00
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cigna Commercial |
$2,380.50
|
| Rate for Payer: Healthspan PPO |
$2,147.62
|
| Rate for Payer: Humana Medicaid |
$1,117.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,247.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,140.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,117.91
|
| Rate for Payer: Multiplan PHCS |
$1,431.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,670.20
|
| Rate for Payer: UHCCP Medicaid |
$835.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,129.09
|
|
|
SIGMOID RESECTION HARTMANS(P
|
Professional
|
Both
|
$2,386.00
|
|
|
Service Code
|
HCPCS 44206
|
| Hospital Charge Code |
761P1830
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$835.10 |
| Max. Negotiated Rate |
$2,546.65 |
| Rate for Payer: Aetna Commercial |
$2,546.65
|
| Rate for Payer: Anthem Medicaid |
$1,117.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,386.00
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cash Price |
$1,193.00
|
| Rate for Payer: Cigna Commercial |
$2,380.50
|
| Rate for Payer: Healthspan PPO |
$2,147.62
|
| Rate for Payer: Humana Medicaid |
$1,117.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,247.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,140.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,117.91
|
| Rate for Payer: Multiplan PHCS |
$1,431.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,670.20
|
| Rate for Payer: UHCCP Medicaid |
$835.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,129.09
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$16,365.79
|
|
|
Service Code
|
MSDRG 555
|
| Min. Negotiated Rate |
$11,105.36 |
| Max. Negotiated Rate |
$16,365.79 |
| Rate for Payer: Anthem Medicaid |
$11,105.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,689.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16,365.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$15,781.30
|
| Rate for Payer: Humana KY Medicaid |
$11,105.36
|
| Rate for Payer: Humana Medicare Advantage |
$11,689.85
|
| Rate for Payer: Kentucky WC Medicaid |
$11,216.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,027.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,327.46
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
|
IP
|
$9,644.00
|
|
|
Service Code
|
MSDRG 556
|
| Min. Negotiated Rate |
$6,544.14 |
| Max. Negotiated Rate |
$9,644.00 |
| Rate for Payer: Anthem Medicaid |
$6,544.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,888.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,644.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,299.57
|
| Rate for Payer: Humana KY Medicaid |
$6,544.14
|
| Rate for Payer: Humana Medicare Advantage |
$6,888.57
|
| Rate for Payer: Kentucky WC Medicaid |
$6,609.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,266.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,675.02
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$14,641.48
|
|
|
Service Code
|
MSDRG 947
|
| Min. Negotiated Rate |
$9,935.29 |
| Max. Negotiated Rate |
$14,641.48 |
| Rate for Payer: Anthem Medicaid |
$9,935.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,458.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,641.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,118.57
|
| Rate for Payer: Humana KY Medicaid |
$9,935.29
|
| Rate for Payer: Humana Medicare Advantage |
$10,458.20
|
| Rate for Payer: Kentucky WC Medicaid |
$10,034.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,549.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,134.00
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$9,370.27
|
|
|
Service Code
|
MSDRG 948
|
| Min. Negotiated Rate |
$6,358.40 |
| Max. Negotiated Rate |
$9,370.27 |
| Rate for Payer: Anthem Medicaid |
$6,358.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,693.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,370.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,035.62
|
| Rate for Payer: Humana KY Medicaid |
$6,358.40
|
| Rate for Payer: Humana Medicare Advantage |
$6,693.05
|
| Rate for Payer: Kentucky WC Medicaid |
$6,421.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,031.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,485.57
|
|
|
SIG W/TNDSC BALLOON DILATION
|
Facility
|
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS 45340
|
| Hospital Charge Code |
76101888
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.50 |
| Max. Negotiated Rate |
$1,428.66 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem Medicaid |
$429.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,020.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,428.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,377.63
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Humana KY Medicaid |
$429.88
|
| Rate for Payer: Humana Medicare Advantage |
$1,020.47
|
| Rate for Payer: Kentucky WC Medicaid |
$434.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,224.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$438.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
SIG W/TNDSC BALLOON DILATION
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 45340
|
| Hospital Charge Code |
76101888
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.12 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Aetna Commercial |
$173.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$79.25
|
| Rate for Payer: Anthem Medicaid |
$69.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$157.94
|
| Rate for Payer: Healthspan PPO |
$509.95
|
| Rate for Payer: Humana Medicaid |
$69.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.50
|
| Rate for Payer: Molina Healthcare Passport |
$69.12
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$83.21
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.81
|
|
|
SIG W/TNDSC BALLOON DILATION
|
Facility
|
IP
|
$1,250.00
|
|
|
Service Code
|
HCPCS 45340
|
| Hospital Charge Code |
76101888
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$375.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
SIG W/TNDSC BALLOON DILATIO(P
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 45340
|
| Hospital Charge Code |
761P1888
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.12 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Aetna Commercial |
$173.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$79.25
|
| Rate for Payer: Anthem Medicaid |
$69.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$157.94
|
| Rate for Payer: Healthspan PPO |
$509.95
|
| Rate for Payer: Humana Medicaid |
$69.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.50
|
| Rate for Payer: Molina Healthcare Passport |
$69.12
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$83.21
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.81
|
|
|
SILICONE CREAM 118 mL
|
Facility
|
IP
|
$8.66
|
|
|
Service Code
|
NDC 53329015904
|
| Hospital Charge Code |
25004459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$8.31 |
| Rate for Payer: Aetna Commercial |
$6.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.75
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna Commercial |
$7.19
|
| Rate for Payer: First Health Commercial |
$8.23
|
| Rate for Payer: Humana Commercial |
$7.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.62
|
| Rate for Payer: Ohio Health Group HMO |
$6.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.68
|
| Rate for Payer: PHCS Commercial |
$8.31
|
| Rate for Payer: United Healthcare All Payer |
$7.62
|
|
|
SILICONE CREAM 118 mL
|
Facility
|
OP
|
$8.66
|
|
|
Service Code
|
NDC 53329015904
|
| Hospital Charge Code |
25004459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$8.31 |
| Rate for Payer: Aetna Commercial |
$6.67
|
| Rate for Payer: Anthem Medicaid |
$2.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.75
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna Commercial |
$7.19
|
| Rate for Payer: First Health Commercial |
$8.23
|
| Rate for Payer: Humana Commercial |
$7.36
|
| Rate for Payer: Humana KY Medicaid |
$2.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.62
|
| Rate for Payer: Ohio Health Group HMO |
$6.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.68
|
| Rate for Payer: PHCS Commercial |
$8.31
|
| Rate for Payer: United Healthcare All Payer |
$7.62
|
|
|
SILICONE CREAM 4 gm
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 53329015977
|
| Hospital Charge Code |
25004460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
SILICONE CREAM 4 gm
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 53329015977
|
| Hospital Charge Code |
25004460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
SILICONE CREAM 59 mL
|
Facility
|
IP
|
$16.26
|
|
|
Service Code
|
NDC 53329015913
|
| Hospital Charge Code |
25004455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.68
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Cigna Commercial |
$13.50
|
| Rate for Payer: First Health Commercial |
$15.45
|
| Rate for Payer: Humana Commercial |
$13.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.31
|
| Rate for Payer: Ohio Health Group HMO |
$12.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.04
|
| Rate for Payer: PHCS Commercial |
$15.61
|
| Rate for Payer: United Healthcare All Payer |
$14.31
|
|
|
SILICONE CREAM 59 mL
|
Facility
|
OP
|
$16.26
|
|
|
Service Code
|
NDC 53329015913
|
| Hospital Charge Code |
25004455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna Commercial |
$12.52
|
| Rate for Payer: Anthem Medicaid |
$5.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.68
|
| Rate for Payer: Cash Price |
$8.13
|
| Rate for Payer: Cigna Commercial |
$13.50
|
| Rate for Payer: First Health Commercial |
$15.45
|
| Rate for Payer: Humana Commercial |
$13.82
|
| Rate for Payer: Humana KY Medicaid |
$5.59
|
| Rate for Payer: Kentucky WC Medicaid |
$5.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.31
|
| Rate for Payer: Ohio Health Group HMO |
$12.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.04
|
| Rate for Payer: PHCS Commercial |
$15.61
|
| Rate for Payer: United Healthcare All Payer |
$14.31
|
|
|
SILICONE TIP STRAIGHT I/A
|
Facility
|
IP
|
$1,555.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$202.20 |
| Max. Negotiated Rate |
$1,493.16 |
| Rate for Payer: Aetna Commercial |
$1,197.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,213.20
|
| Rate for Payer: Cash Price |
$777.69
|
| Rate for Payer: Cigna Commercial |
$1,290.97
|
| Rate for Payer: First Health Commercial |
$1,477.61
|
| Rate for Payer: Humana Commercial |
$1,322.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,275.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,147.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,368.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,166.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$311.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$202.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$482.17
|
| Rate for Payer: PHCS Commercial |
$1,493.16
|
| Rate for Payer: United Healthcare All Payer |
$1,368.73
|
|
