|
BLEPHAROPLASTY UPPER EYELID(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
761P0216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.75 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$845.31
|
| Rate for Payer: Anthem Medicaid |
$416.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| 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 |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$420.92
|
|
|
BLEPHAROPLASTY, UPPER EYELID(P
|
Professional
|
Both
|
$1,380.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
761P0215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.62 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Aetna Commercial |
$515.24
|
| Rate for Payer: Anthem Medicaid |
$285.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,380.00
|
| Rate for Payer: Cash Price |
$690.00
|
| Rate for Payer: Cash Price |
$690.00
|
| 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 |
$828.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$966.00
|
| Rate for Payer: UHCCP Medicaid |
$483.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.48
|
|
|
BLEPHAROPLASTY UPPER EYELID(T
|
Facility
|
OP
|
$4,220.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
761T0216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$548.60 |
| Max. Negotiated Rate |
$4,051.20 |
| Rate for Payer: Aetna Commercial |
$3,249.40
|
| Rate for Payer: Anthem Medicaid |
$1,451.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,291.60
|
| 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 |
$2,110.00
|
| Rate for Payer: Cash Price |
$2,110.00
|
| Rate for Payer: Cigna Commercial |
$3,502.60
|
| Rate for Payer: First Health Commercial |
$4,009.00
|
| Rate for Payer: Humana Commercial |
$3,587.00
|
| Rate for Payer: Humana KY Medicaid |
$1,451.26
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,466.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,460.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,114.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,480.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.20
|
| Rate for Payer: PHCS Commercial |
$4,051.20
|
| Rate for Payer: United Healthcare All Payer |
$3,713.60
|
|
|
BLEPHAROPLASTY UPPER EYELID(T
|
Facility
|
IP
|
$4,220.00
|
|
|
Service Code
|
HCPCS 15823
|
| Hospital Charge Code |
761T0216
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$548.60 |
| Max. Negotiated Rate |
$4,051.20 |
| Rate for Payer: Aetna Commercial |
$3,249.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,291.60
|
| Rate for Payer: Cash Price |
$2,110.00
|
| Rate for Payer: Cigna Commercial |
$3,502.60
|
| Rate for Payer: First Health Commercial |
$4,009.00
|
| Rate for Payer: Humana Commercial |
$3,587.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,460.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,114.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,713.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.20
|
| Rate for Payer: PHCS Commercial |
$4,051.20
|
| Rate for Payer: United Healthcare All Payer |
$3,713.60
|
|
|
BLEPHAROPLASTY, UPPER EYELID(T
|
Facility
|
OP
|
$4,972.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
761T0215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$646.36 |
| Max. Negotiated Rate |
$4,773.12 |
| Rate for Payer: Aetna Commercial |
$3,828.44
|
| Rate for Payer: Anthem Medicaid |
$1,709.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,878.16
|
| 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 |
$2,486.00
|
| Rate for Payer: Cash Price |
$2,486.00
|
| Rate for Payer: Cigna Commercial |
$4,126.76
|
| Rate for Payer: First Health Commercial |
$4,723.40
|
| Rate for Payer: Humana Commercial |
$4,226.20
|
| Rate for Payer: Humana KY Medicaid |
$1,709.87
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,727.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,077.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,669.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,744.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,375.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,729.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$994.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$646.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,541.32
|
| Rate for Payer: PHCS Commercial |
$4,773.12
|
| Rate for Payer: United Healthcare All Payer |
$4,375.36
|
|
|
BLEPHAROPLASTY, UPPER EYELID(T
|
Facility
|
IP
|
$4,972.00
|
|
|
Service Code
|
HCPCS 15822
|
| Hospital Charge Code |
761T0215
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$646.36 |
| Max. Negotiated Rate |
$4,773.12 |
| Rate for Payer: Aetna Commercial |
$3,828.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,878.16
|
| Rate for Payer: Cash Price |
$2,486.00
|
| Rate for Payer: Cigna Commercial |
$4,126.76
|
| Rate for Payer: First Health Commercial |
$4,723.40
|
| Rate for Payer: Humana Commercial |
$4,226.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,077.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,669.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,491.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,375.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,729.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$994.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$646.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,541.32
|
| Rate for Payer: PHCS Commercial |
$4,773.12
|
| Rate for Payer: United Healthcare All Payer |
$4,375.36
|
|
|
BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
|
Facility
|
OP
|
$2,207.77
|
|
|
Service Code
|
CPT 15823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.98 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
|
|
BLEPHAROPLASTY (UPPER&LOWER)
|
Professional
|
Both
|
$1,770.00
|
|
| Hospital Charge Code |
22200038
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$619.50 |
| Max. Negotiated Rate |
$1,770.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,770.00
|
| Rate for Payer: Cash Price |
$885.00
|
| Rate for Payer: Multiplan PHCS |
$1,062.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,239.00
|
| Rate for Payer: UHCCP Medicaid |
$619.50
|
|
|
BLEPHAROPLASY(UP &LOW OR)-80
|
Professional
|
Both
|
$885.00
|
|
| Hospital Charge Code |
22200372
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$309.75 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$885.00
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Multiplan PHCS |
$531.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$619.50
|
| Rate for Payer: UHCCP Medicaid |
$309.75
|
|
|
BLEPH (BOTH UPPER EYELIDS)
|
Professional
|
Both
|
$2,000.00
|
|
| Hospital Charge Code |
22200193
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
|
|
BLEPH (SINGLE UPPER EYELID)
|
Professional
|
Both
|
$1,000.00
|
|
| Hospital Charge Code |
22200694
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
|
|
BLOCADREN (TIMOLOL) 10MG/1TAB
|
Facility
|
OP
|
$9.36
|
|
|
Service Code
|
NDC 378022101
|
| Hospital Charge Code |
25000343
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem Medicaid |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.77
|
| Rate for Payer: First Health Commercial |
$8.89
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Humana KY Medicaid |
$3.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.99
|
| Rate for Payer: United Healthcare All Payer |
$8.24
|
|
|
BLOCADREN (TIMOLOL) 10MG/1TAB
|
Facility
|
IP
|
$9.36
|
|
|
Service Code
|
NDC 378022101
|
| Hospital Charge Code |
25000343
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.77
|
| Rate for Payer: First Health Commercial |
$8.89
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.99
|
| Rate for Payer: United Healthcare All Payer |
$8.24
|
|
|
BLOCK S&N FEMUR LEFT
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
BLOCK S&N FEMUR LEFT
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
BLOCK S&N FEMUR RIGHT
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
BLOCK S&N FEMUR RIGHT
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
BLOOD ADMINISTRATION
|
Professional
|
Both
|
$1,215.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
38000001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$1,215.00 |
| Rate for Payer: Aetna Commercial |
$54.57
|
| Rate for Payer: Anthem Medicaid |
$14.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,215.00
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$57.98
|
| Rate for Payer: Healthspan PPO |
$43.64
|
| Rate for Payer: Humana Medicaid |
$14.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$14.87
|
| Rate for Payer: Molina Healthcare Passport |
$14.58
|
| Rate for Payer: Multiplan PHCS |
$729.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$850.50
|
| Rate for Payer: UHCCP Medicaid |
$425.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$14.73
|
|
|
BLOOD ADMINISTRATION
|
Facility
|
OP
|
$1,215.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
38000001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$157.95 |
| Max. Negotiated Rate |
$1,166.40 |
| Rate for Payer: Aetna Commercial |
$935.55
|
| Rate for Payer: Anthem Medicaid |
$417.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$375.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$947.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$525.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$506.78
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$1,008.45
|
| Rate for Payer: First Health Commercial |
$1,154.25
|
| Rate for Payer: Humana Commercial |
$1,032.75
|
| Rate for Payer: Humana KY Medicaid |
$417.84
|
| Rate for Payer: Humana Medicare Advantage |
$375.39
|
| Rate for Payer: Kentucky WC Medicaid |
$422.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$996.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$896.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$426.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,069.20
|
| Rate for Payer: Ohio Health Group HMO |
$911.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.65
|
| Rate for Payer: PHCS Commercial |
$1,166.40
|
| Rate for Payer: United Healthcare All Payer |
$1,069.20
|
|
|
BLOOD ADMINISTRATION
|
Facility
|
IP
|
$1,215.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
38000001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$157.95 |
| Max. Negotiated Rate |
$1,166.40 |
| Rate for Payer: Aetna Commercial |
$935.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$947.70
|
| Rate for Payer: Cash Price |
$607.50
|
| Rate for Payer: Cigna Commercial |
$1,008.45
|
| Rate for Payer: First Health Commercial |
$1,154.25
|
| Rate for Payer: Humana Commercial |
$1,032.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$996.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$896.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$364.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,069.20
|
| Rate for Payer: Ohio Health Group HMO |
$911.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.65
|
| Rate for Payer: PHCS Commercial |
$1,166.40
|
| Rate for Payer: United Healthcare All Payer |
$1,069.20
|
|
|
BLOOD ADMINISTRATION(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
380P0001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$54.57
|
| Rate for Payer: Anthem Medicaid |
$14.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$57.98
|
| Rate for Payer: Healthspan PPO |
$43.64
|
| Rate for Payer: Humana Medicaid |
$14.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$14.87
|
| Rate for Payer: Molina Healthcare Passport |
$14.58
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$14.73
|
|
|
BLOOD ADMINISTRATION(T
|
Facility
|
IP
|
$980.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
380T0001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$940.80 |
| Rate for Payer: Aetna Commercial |
$754.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$764.40
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cigna Commercial |
$813.40
|
| Rate for Payer: First Health Commercial |
$931.00
|
| Rate for Payer: Humana Commercial |
$833.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$803.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$723.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$862.40
|
| Rate for Payer: Ohio Health Group HMO |
$735.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.80
|
| Rate for Payer: PHCS Commercial |
$940.80
|
| Rate for Payer: United Healthcare All Payer |
$862.40
|
|
|
BLOOD ADMINISTRATION(T
|
Facility
|
OP
|
$980.00
|
|
|
Service Code
|
HCPCS 36430
|
| Hospital Charge Code |
380T0001
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$940.80 |
| Rate for Payer: Aetna Commercial |
$754.60
|
| Rate for Payer: Anthem Medicaid |
$337.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$375.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$764.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$525.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$506.78
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cigna Commercial |
$813.40
|
| Rate for Payer: First Health Commercial |
$931.00
|
| Rate for Payer: Humana Commercial |
$833.00
|
| Rate for Payer: Humana KY Medicaid |
$337.02
|
| Rate for Payer: Humana Medicare Advantage |
$375.39
|
| Rate for Payer: Kentucky WC Medicaid |
$340.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$803.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$723.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$862.40
|
| Rate for Payer: Ohio Health Group HMO |
$735.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.80
|
| Rate for Payer: PHCS Commercial |
$940.80
|
| Rate for Payer: United Healthcare All Payer |
$862.40
|
|
|
BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT
|
Facility
|
OP
|
$10.88
|
|
|
Service Code
|
CPT 85025
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7.77 |
| Max. Negotiated Rate |
$10.88 |
| Rate for Payer: Anthem Medicaid |
$7.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.77
|
| Rate for Payer: Humana KY Medicaid |
$7.77
|
| Rate for Payer: Humana Medicare Advantage |
$7.77
|
| Rate for Payer: Kentucky WC Medicaid |
$7.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.93
|
|
|
BLOOD GASES
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 82803
|
| Hospital Charge Code |
30000334
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$124.80 |
| Rate for Payer: Aetna Commercial |
$100.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.39
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$107.90
|
| Rate for Payer: First Health Commercial |
$123.50
|
| Rate for Payer: Humana Commercial |
$110.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.40
|
| Rate for Payer: Ohio Health Group HMO |
$97.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.30
|
| Rate for Payer: PHCS Commercial |
$124.80
|
| Rate for Payer: United Healthcare All Payer |
$114.40
|
|
