|
BLD SMEAR WO DIFF WBC COUNT
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
HCPCS 85008
|
| Hospital Charge Code |
30001811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem Medicaid |
$12.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.43
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Humana KY Medicaid |
$12.72
|
| Rate for Payer: Humana Medicare Advantage |
$3.43
|
| Rate for Payer: Kentucky WC Medicaid |
$12.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.47
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
BLD SMEAR WO DIFF WBC COUNT
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 85008
|
| Hospital Charge Code |
30001811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.00
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$4.98
|
| Rate for Payer: Healthspan PPO |
$1.66
|
| Rate for Payer: Multiplan PHCS |
$22.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.90
|
| Rate for Payer: UHCCP Medicaid |
$12.95
|
|
|
BLD SMEAR WO DIFF WBC COUNT
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
HCPCS 85008
|
| Hospital Charge Code |
30001811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$35.52 |
| Rate for Payer: Aetna Commercial |
$28.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.71
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cigna Commercial |
$30.71
|
| Rate for Payer: First Health Commercial |
$35.15
|
| Rate for Payer: Humana Commercial |
$31.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.56
|
| Rate for Payer: Ohio Health Group HMO |
$27.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.47
|
| Rate for Payer: PHCS Commercial |
$35.52
|
| Rate for Payer: United Healthcare All Payer |
$32.56
|
|
|
BLEOMYCIN 30 UNIT VIAL
|
Facility
|
OP
|
$363.46
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
25002569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$348.92 |
| Rate for Payer: Aetna Commercial |
$279.86
|
| Rate for Payer: Anthem Medicaid |
$124.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.50
|
| Rate for Payer: Cash Price |
$181.73
|
| Rate for Payer: Cigna Commercial |
$301.67
|
| Rate for Payer: First Health Commercial |
$345.29
|
| Rate for Payer: Humana Commercial |
$308.94
|
| Rate for Payer: Humana KY Medicaid |
$124.99
|
| Rate for Payer: Kentucky WC Medicaid |
$126.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$298.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.84
|
| Rate for Payer: Ohio Health Group HMO |
$272.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.67
|
| Rate for Payer: PHCS Commercial |
$348.92
|
| Rate for Payer: United Healthcare All Payer |
$319.84
|
|
|
BLEOMYCIN 30 UNIT VIAL
|
Facility
|
IP
|
$363.46
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
25002569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$348.92 |
| Rate for Payer: Aetna Commercial |
$279.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.50
|
| Rate for Payer: Cash Price |
$181.73
|
| Rate for Payer: Cigna Commercial |
$301.67
|
| Rate for Payer: First Health Commercial |
$345.29
|
| Rate for Payer: Humana Commercial |
$308.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$298.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$319.84
|
| Rate for Payer: Ohio Health Group HMO |
$272.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.67
|
| Rate for Payer: PHCS Commercial |
$348.92
|
| Rate for Payer: United Healthcare All Payer |
$319.84
|
|
|
BLEOMYCIN SULFATE15 UNIT VIAL
|
Facility
|
OP
|
$180.50
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
25002570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$173.28 |
| Rate for Payer: Aetna Commercial |
$138.98
|
| Rate for Payer: Anthem Medicaid |
$62.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.79
|
| Rate for Payer: Cash Price |
$90.25
|
| Rate for Payer: Cigna Commercial |
$149.82
|
| Rate for Payer: First Health Commercial |
$171.48
|
| Rate for Payer: Humana Commercial |
$153.42
|
| Rate for Payer: Humana KY Medicaid |
$62.07
|
| Rate for Payer: Kentucky WC Medicaid |
$62.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.84
|
| Rate for Payer: Ohio Health Group HMO |
$135.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.96
|
| Rate for Payer: PHCS Commercial |
$173.28
|
| Rate for Payer: United Healthcare All Payer |
$158.84
|
|
|
BLEOMYCIN SULFATE15 UNIT VIAL
|
Facility
|
IP
|
$180.50
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
25002570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$173.28 |
| Rate for Payer: Aetna Commercial |
$138.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.79
|
| Rate for Payer: Cash Price |
$90.25
|
| Rate for Payer: Cigna Commercial |
$149.82
|
| Rate for Payer: First Health Commercial |
$171.48
|
| Rate for Payer: Humana Commercial |
$153.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.84
|
| Rate for Payer: Ohio Health Group HMO |
$135.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.96
|
| Rate for Payer: PHCS Commercial |
$173.28
|
| Rate for Payer: United Healthcare All Payer |
$158.84
|
|
|
BLEPH-10(SULFACETAMIDE) 1 15ML
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
25000340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna Commercial |
$0.56
|
| Rate for Payer: First Health Commercial |
$0.64
|
| Rate for Payer: Humana Commercial |
$0.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.59
|
| Rate for Payer: Ohio Health Group HMO |
$0.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.21
|
| Rate for Payer: PHCS Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Payer |
$0.59
|
|
|
BLEPH-10(SULFACETAMIDE) 1 15ML
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 24208067004
|
| Hospital Charge Code |
25000340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna Commercial |
$0.52
|
| Rate for Payer: Anthem Medicaid |
$0.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.52
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna Commercial |
$0.56
|
| Rate for Payer: First Health Commercial |
$0.64
|
| Rate for Payer: Humana Commercial |
$0.57
|
| Rate for Payer: Humana KY Medicaid |
$0.23
|
| Rate for Payer: Kentucky WC Medicaid |
$0.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.59
|
| Rate for Payer: Ohio Health Group HMO |
$0.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.21
|
| Rate for Payer: PHCS Commercial |
$0.64
|
| Rate for Payer: United Healthcare All Payer |
$0.59
|
|
|
BLEPHAROPLASTY, LOWER EYELID
|
Professional
|
Both
|
$4,665.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
76100214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$321.09 |
| Max. Negotiated Rate |
$4,665.00 |
| Rate for Payer: Aetna Commercial |
$670.68
|
| Rate for Payer: Anthem Medicaid |
$321.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,665.00
|
| Rate for Payer: Cash Price |
$2,332.50
|
| Rate for Payer: Cash Price |
$2,332.50
|
| Rate for Payer: Cigna Commercial |
$649.50
|
| Rate for Payer: Healthspan PPO |
$589.34
|
| Rate for Payer: Humana Medicaid |
$321.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$327.51
|
| Rate for Payer: Molina Healthcare Passport |
$321.09
|
| Rate for Payer: Multiplan PHCS |
$2,799.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,265.50
|
| Rate for Payer: UHCCP Medicaid |
$1,632.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.30
|
|
|
BLEPHAROPLASTY, LOWER EYELID
|
Facility
|
IP
|
$4,665.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
76100214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$4,478.40 |
| Rate for Payer: Aetna Commercial |
$3,592.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,638.70
|
| Rate for Payer: Cash Price |
$2,332.50
|
| Rate for Payer: Cigna Commercial |
$3,871.95
|
| Rate for Payer: First Health Commercial |
$4,431.75
|
| Rate for Payer: Humana Commercial |
$3,965.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,825.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,442.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,399.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,498.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$606.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,446.15
|
| Rate for Payer: PHCS Commercial |
$4,478.40
|
| Rate for Payer: United Healthcare All Payer |
$4,105.20
|
|
|
BLEPHAROPLASTY, LOWER EYELID
|
Facility
|
OP
|
$4,665.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
76100214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$606.45 |
| Max. Negotiated Rate |
$4,478.40 |
| Rate for Payer: Aetna Commercial |
$3,592.05
|
| Rate for Payer: Anthem Medicaid |
$1,604.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,638.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,332.50
|
| Rate for Payer: Cash Price |
$2,332.50
|
| Rate for Payer: Cigna Commercial |
$3,871.95
|
| Rate for Payer: First Health Commercial |
$4,431.75
|
| Rate for Payer: Humana Commercial |
$3,965.25
|
| Rate for Payer: Humana KY Medicaid |
$1,604.29
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,620.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,825.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,442.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,636.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,498.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$606.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,446.15
|
| Rate for Payer: PHCS Commercial |
$4,478.40
|
| Rate for Payer: United Healthcare All Payer |
$4,105.20
|
|
|
BLEPHAROPLASTY, LOWER EYELID(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
761P0214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$670.68
|
| Rate for Payer: Anthem Medicaid |
$321.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$649.50
|
| Rate for Payer: Healthspan PPO |
$589.34
|
| Rate for Payer: Humana Medicaid |
$321.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$327.51
|
| Rate for Payer: Molina Healthcare Passport |
$321.09
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.30
|
|
|
BLEPHAROPLASTY (LOWER EYELIDS)
|
Professional
|
Both
|
$1,170.00
|
|
| Hospital Charge Code |
22200040
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,170.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,170.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Multiplan PHCS |
$702.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$819.00
|
| Rate for Payer: UHCCP Medicaid |
$409.50
|
|
|
BLEPHAROPLASTY, LOWER EYELID(T
|
Facility
|
IP
|
$3,915.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
761T0214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
BLEPHAROPLASTY, LOWER EYELID(T
|
Facility
|
OP
|
$3,915.00
|
|
|
Service Code
|
HCPCS 15820
|
| Hospital Charge Code |
761T0214
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.95 |
| Max. Negotiated Rate |
$3,758.40 |
| Rate for Payer: Aetna Commercial |
$3,014.55
|
| Rate for Payer: Anthem Medicaid |
$1,346.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,053.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cash Price |
$1,957.50
|
| Rate for Payer: Cigna Commercial |
$3,249.45
|
| Rate for Payer: First Health Commercial |
$3,719.25
|
| Rate for Payer: Humana Commercial |
$3,327.75
|
| Rate for Payer: Humana KY Medicaid |
$1,346.37
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,360.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,210.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,889.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,445.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,936.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,213.65
|
| Rate for Payer: PHCS Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare All Payer |
$3,445.20
|
|
|
BLEPHAROPLASTY(LOW ONLY OR)-80
|
Professional
|
Both
|
$585.00
|
|
| Hospital Charge Code |
22200375
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$585.00
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Multiplan PHCS |
$351.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$409.50
|
| Rate for Payer: UHCCP Medicaid |
$204.75
|
|
|
BLEPHAROPLASTY (UP ONLY IN OR)
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200039
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
BLEPHAROPLASTY(UP ONLY OR)-80
|
Professional
|
Both
|
$300.00
|
|
| Hospital Charge Code |
22200374
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
|
|
BLEPHAROPLASTY UPPER EYELID
|
Facility
|
IP
|
$5,420.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
76100216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$704.60 |
| Max. Negotiated Rate |
$5,203.20 |
| Rate for Payer: Aetna Commercial |
$4,173.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,227.60
|
| Rate for Payer: Cash Price |
$2,710.00
|
| Rate for Payer: Cigna Commercial |
$4,498.60
|
| Rate for Payer: First Health Commercial |
$5,149.00
|
| Rate for Payer: Humana Commercial |
$4,607.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,444.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,999.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,626.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,769.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,065.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,084.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,680.20
|
| Rate for Payer: PHCS Commercial |
$5,203.20
|
| Rate for Payer: United Healthcare All Payer |
$4,769.60
|
|
|
BLEPHAROPLASTY UPPER EYELID
|
Professional
|
Both
|
$5,420.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
76100216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.75 |
| Max. Negotiated Rate |
$5,420.00 |
| Rate for Payer: Aetna Commercial |
$845.31
|
| Rate for Payer: Anthem Medicaid |
$416.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,420.00
|
| Rate for Payer: Cash Price |
$2,710.00
|
| Rate for Payer: Cash Price |
$2,710.00
|
| Rate for Payer: Cigna Commercial |
$812.80
|
| Rate for Payer: Healthspan PPO |
$731.11
|
| Rate for Payer: Humana Medicaid |
$416.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$686.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$425.08
|
| Rate for Payer: Molina Healthcare Passport |
$416.75
|
| Rate for Payer: Multiplan PHCS |
$3,252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,794.00
|
| Rate for Payer: UHCCP Medicaid |
$1,897.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$420.92
|
|
|
BLEPHAROPLASTY UPPER EYELID
|
Facility
|
OP
|
$5,420.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
76100216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$704.60 |
| Max. Negotiated Rate |
$5,203.20 |
| Rate for Payer: Aetna Commercial |
$4,173.40
|
| Rate for Payer: Anthem Medicaid |
$1,863.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,227.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,710.00
|
| Rate for Payer: Cash Price |
$2,710.00
|
| Rate for Payer: Cigna Commercial |
$4,498.60
|
| Rate for Payer: First Health Commercial |
$5,149.00
|
| Rate for Payer: Humana Commercial |
$4,607.00
|
| Rate for Payer: Humana KY Medicaid |
$1,863.94
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,882.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,444.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,999.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,901.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,769.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,065.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,084.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,680.20
|
| Rate for Payer: PHCS Commercial |
$5,203.20
|
| Rate for Payer: United Healthcare All Payer |
$4,769.60
|
|
|
BLEPHAROPLASTY, UPPER EYELID
|
Facility
|
IP
|
$6,352.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
76100215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$825.76 |
| Max. Negotiated Rate |
$6,097.92 |
| Rate for Payer: Aetna Commercial |
$4,891.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,954.56
|
| Rate for Payer: Cash Price |
$3,176.00
|
| Rate for Payer: Cigna Commercial |
$5,272.16
|
| Rate for Payer: First Health Commercial |
$6,034.40
|
| Rate for Payer: Humana Commercial |
$5,399.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,208.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,687.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,905.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,589.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,764.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$825.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,969.12
|
| Rate for Payer: PHCS Commercial |
$6,097.92
|
| Rate for Payer: United Healthcare All Payer |
$5,589.76
|
|
|
BLEPHAROPLASTY, UPPER EYELID
|
Facility
|
OP
|
$6,352.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
76100215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$825.76 |
| Max. Negotiated Rate |
$6,097.92 |
| Rate for Payer: Aetna Commercial |
$4,891.04
|
| Rate for Payer: Anthem Medicaid |
$2,184.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,954.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,176.00
|
| Rate for Payer: Cash Price |
$3,176.00
|
| Rate for Payer: Cigna Commercial |
$5,272.16
|
| Rate for Payer: First Health Commercial |
$6,034.40
|
| Rate for Payer: Humana Commercial |
$5,399.20
|
| Rate for Payer: Humana KY Medicaid |
$2,184.45
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,206.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,208.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,687.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,228.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,589.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,764.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$825.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,969.12
|
| Rate for Payer: PHCS Commercial |
$6,097.92
|
| Rate for Payer: United Healthcare All Payer |
$5,589.76
|
|
|
BLEPHAROPLASTY, UPPER EYELID
|
Professional
|
Both
|
$6,352.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
76100215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.62 |
| Max. Negotiated Rate |
$6,352.00 |
| Rate for Payer: Aetna Commercial |
$515.24
|
| Rate for Payer: Anthem Medicaid |
$285.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,352.00
|
| Rate for Payer: Cash Price |
$3,176.00
|
| Rate for Payer: Cash Price |
$3,176.00
|
| Rate for Payer: Cigna Commercial |
$504.96
|
| Rate for Payer: Healthspan PPO |
$462.48
|
| Rate for Payer: Humana Medicaid |
$285.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$473.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$291.33
|
| Rate for Payer: Molina Healthcare Passport |
$285.62
|
| Rate for Payer: Multiplan PHCS |
$3,811.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,446.40
|
| Rate for Payer: UHCCP Medicaid |
$2,223.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.48
|
|
