|
SURGICAL OPENING OF STOMACH(T
|
Facility
|
OP
|
$1,126.00
|
|
|
Service Code
|
HCPCS 43510
|
| Hospital Charge Code |
761T1781
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.38 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$867.02
|
| Rate for Payer: Anthem Medicaid |
$387.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$878.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$563.00
|
| Rate for Payer: Cash Price |
$563.00
|
| Rate for Payer: Cigna Commercial |
$934.58
|
| Rate for Payer: First Health Commercial |
$1,069.70
|
| Rate for Payer: Humana Commercial |
$957.10
|
| Rate for Payer: Humana KY Medicaid |
$387.23
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$391.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$923.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.88
|
| Rate for Payer: Ohio Health Group HMO |
$844.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.06
|
| Rate for Payer: PHCS Commercial |
$1,080.96
|
| Rate for Payer: United Healthcare All Payer |
$990.88
|
|
|
SURGICAL OPENING OF STOMACH(T
|
Facility
|
IP
|
$1,126.00
|
|
|
Service Code
|
HCPCS 43510
|
| Hospital Charge Code |
761T1781
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.38 |
| Max. Negotiated Rate |
$1,080.96 |
| Rate for Payer: Aetna Commercial |
$867.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$878.28
|
| Rate for Payer: Cash Price |
$563.00
|
| Rate for Payer: Cigna Commercial |
$934.58
|
| Rate for Payer: First Health Commercial |
$1,069.70
|
| Rate for Payer: Humana Commercial |
$957.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$923.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.88
|
| Rate for Payer: Ohio Health Group HMO |
$844.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.06
|
| Rate for Payer: PHCS Commercial |
$1,080.96
|
| Rate for Payer: United Healthcare All Payer |
$990.88
|
|
|
SURGICAL PATH GROSS
|
Facility
|
OP
|
$219.00
|
|
|
Service Code
|
HCPCS 88300
|
| Hospital Charge Code |
30001502
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$25.75 |
| Max. Negotiated Rate |
$210.24 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Anthem Medicaid |
$75.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$175.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.76
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$181.77
|
| Rate for Payer: First Health Commercial |
$208.05
|
| Rate for Payer: Humana Commercial |
$186.15
|
| Rate for Payer: Humana KY Medicaid |
$75.31
|
| Rate for Payer: Humana Medicare Advantage |
$25.75
|
| Rate for Payer: Kentucky WC Medicaid |
$76.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.72
|
| Rate for Payer: Ohio Health Group HMO |
$164.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.89
|
| Rate for Payer: PHCS Commercial |
$210.24
|
| Rate for Payer: United Healthcare All Payer |
$192.72
|
|
|
SURGICAL PATH GROSS
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
HCPCS 88300
|
| Hospital Charge Code |
30001502
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: Aetna Commercial |
$34.95
|
| Rate for Payer: Anthem Medicaid |
$12.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$219.00
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$14.03
|
| Rate for Payer: Healthspan PPO |
$33.18
|
| Rate for Payer: Humana Medicaid |
$12.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.60
|
| Rate for Payer: Molina Healthcare Passport |
$12.35
|
| Rate for Payer: Multiplan PHCS |
$131.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$153.30
|
| Rate for Payer: UHCCP Medicaid |
$76.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.47
|
|
|
SURGICAL PATH GROSS
|
Facility
|
IP
|
$219.00
|
|
|
Service Code
|
HCPCS 88300
|
| Hospital Charge Code |
30001502
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$28.47 |
| Max. Negotiated Rate |
$210.24 |
| Rate for Payer: Aetna Commercial |
$168.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$175.86
|
| Rate for Payer: Cash Price |
$109.50
|
| Rate for Payer: Cigna Commercial |
$181.77
|
| Rate for Payer: First Health Commercial |
$208.05
|
| Rate for Payer: Humana Commercial |
$186.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$179.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$161.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$192.72
|
| Rate for Payer: Ohio Health Group HMO |
$164.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.89
|
| Rate for Payer: PHCS Commercial |
$210.24
|
| Rate for Payer: United Healthcare All Payer |
$192.72
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$760.35
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$543.11 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
|
|
SURGICEL 2 X 0.5 (OXIDIZED 1EA
|
Facility
|
OP
|
$37.02
|
|
|
Service Code
|
NDC 63713001955
|
| Hospital Charge Code |
27000226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$35.54 |
| Rate for Payer: Aetna Commercial |
$28.51
|
| Rate for Payer: Anthem Medicaid |
$12.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.88
|
| Rate for Payer: Cash Price |
$18.51
|
| Rate for Payer: Cigna Commercial |
$30.73
|
| Rate for Payer: First Health Commercial |
$35.17
|
| Rate for Payer: Humana Commercial |
$31.47
|
| Rate for Payer: Humana KY Medicaid |
$12.73
|
| Rate for Payer: Kentucky WC Medicaid |
$12.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.58
|
| Rate for Payer: Ohio Health Group HMO |
$27.76
|
| 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 |
$11.48
|
| Rate for Payer: PHCS Commercial |
$35.54
|
| Rate for Payer: United Healthcare All Payer |
$32.58
|
|
|
SURGICEL 2 X 0.5 (OXIDIZED 1EA
|
Facility
|
IP
|
$37.02
|
|
|
Service Code
|
NDC 63713001955
|
| Hospital Charge Code |
27000226
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$35.54 |
| Rate for Payer: Aetna Commercial |
$28.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.88
|
| Rate for Payer: Cash Price |
$18.51
|
| Rate for Payer: Cigna Commercial |
$30.73
|
| Rate for Payer: First Health Commercial |
$35.17
|
| Rate for Payer: Humana Commercial |
$31.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.58
|
| Rate for Payer: Ohio Health Group HMO |
$27.76
|
| 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 |
$11.48
|
| Rate for Payer: PHCS Commercial |
$35.54
|
| Rate for Payer: United Healthcare All Payer |
$32.58
|
|
|
SURGICEL 2 X 14 (OXIDIZED 1EA
|
Facility
|
IP
|
$137.61
|
|
|
Service Code
|
NDC 63713001951
|
| Hospital Charge Code |
27000224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.89 |
| Max. Negotiated Rate |
$132.11 |
| Rate for Payer: Aetna Commercial |
$105.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.34
|
| Rate for Payer: Cash Price |
$68.81
|
| Rate for Payer: Cigna Commercial |
$114.22
|
| Rate for Payer: First Health Commercial |
$130.73
|
| Rate for Payer: Humana Commercial |
$116.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$112.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.10
|
| Rate for Payer: Ohio Health Group HMO |
$103.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.66
|
| Rate for Payer: PHCS Commercial |
$132.11
|
| Rate for Payer: United Healthcare All Payer |
$121.10
|
|
|
SURGICEL 2 X 14 (OXIDIZED 1EA
|
Facility
|
OP
|
$137.61
|
|
|
Service Code
|
NDC 63713001951
|
| Hospital Charge Code |
27000224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.89 |
| Max. Negotiated Rate |
$132.11 |
| Rate for Payer: Aetna Commercial |
$105.96
|
| Rate for Payer: Anthem Medicaid |
$47.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.34
|
| Rate for Payer: Cash Price |
$68.81
|
| Rate for Payer: Cigna Commercial |
$114.22
|
| Rate for Payer: First Health Commercial |
$130.73
|
| Rate for Payer: Humana Commercial |
$116.97
|
| Rate for Payer: Humana KY Medicaid |
$47.32
|
| Rate for Payer: Kentucky WC Medicaid |
$47.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$112.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$48.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.10
|
| Rate for Payer: Ohio Health Group HMO |
$103.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.66
|
| Rate for Payer: PHCS Commercial |
$132.11
|
| Rate for Payer: United Healthcare All Payer |
$121.10
|
|
|
SURGICEL 2 X 14 (OXIDIZED 1EA
|
Facility
|
IP
|
$116.42
|
|
| Hospital Charge Code |
27000224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$111.76 |
| Rate for Payer: Aetna Commercial |
$89.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.81
|
| Rate for Payer: Cash Price |
$58.21
|
| Rate for Payer: Cigna Commercial |
$96.63
|
| Rate for Payer: First Health Commercial |
$110.60
|
| Rate for Payer: Humana Commercial |
$98.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.45
|
| Rate for Payer: Ohio Health Group HMO |
$87.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.09
|
| Rate for Payer: PHCS Commercial |
$111.76
|
| Rate for Payer: United Healthcare All Payer |
$102.45
|
|
|
SURGICEL 2 X 14 (OXIDIZED 1EA
|
Facility
|
OP
|
$116.42
|
|
| Hospital Charge Code |
27000224
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$111.76 |
| Rate for Payer: Aetna Commercial |
$89.64
|
| Rate for Payer: Anthem Medicaid |
$40.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.81
|
| Rate for Payer: Cash Price |
$58.21
|
| Rate for Payer: Cigna Commercial |
$96.63
|
| Rate for Payer: First Health Commercial |
$110.60
|
| Rate for Payer: Humana Commercial |
$98.96
|
| Rate for Payer: Humana KY Medicaid |
$40.04
|
| Rate for Payer: Kentucky WC Medicaid |
$40.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.45
|
| Rate for Payer: Ohio Health Group HMO |
$87.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.09
|
| Rate for Payer: PHCS Commercial |
$111.76
|
| Rate for Payer: United Healthcare All Payer |
$102.45
|
|
|
SURGICEL 2 X 3 (OXIDIZED C 1EA
|
Facility
|
OP
|
$76.51
|
|
|
Service Code
|
NDC 63713001953
|
| Hospital Charge Code |
27000225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$73.45 |
| Rate for Payer: Aetna Commercial |
$58.91
|
| Rate for Payer: Anthem Medicaid |
$26.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.68
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cigna Commercial |
$63.50
|
| Rate for Payer: First Health Commercial |
$72.68
|
| Rate for Payer: Humana Commercial |
$65.03
|
| Rate for Payer: Humana KY Medicaid |
$26.31
|
| Rate for Payer: Kentucky WC Medicaid |
$26.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.33
|
| Rate for Payer: Ohio Health Group HMO |
$57.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.72
|
| Rate for Payer: PHCS Commercial |
$73.45
|
| Rate for Payer: United Healthcare All Payer |
$67.33
|
|
|
SURGICEL 2 X 3 (OXIDIZED C 1EA
|
Facility
|
OP
|
$65.88
|
|
| Hospital Charge Code |
27000225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$63.24 |
| Rate for Payer: Aetna Commercial |
$50.73
|
| Rate for Payer: Anthem Medicaid |
$22.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
| Rate for Payer: Cash Price |
$32.94
|
| Rate for Payer: Cigna Commercial |
$54.68
|
| Rate for Payer: First Health Commercial |
$62.59
|
| Rate for Payer: Humana Commercial |
$56.00
|
| Rate for Payer: Humana KY Medicaid |
$22.66
|
| Rate for Payer: Kentucky WC Medicaid |
$22.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.97
|
| Rate for Payer: Ohio Health Group HMO |
$49.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.42
|
| Rate for Payer: PHCS Commercial |
$63.24
|
| Rate for Payer: United Healthcare All Payer |
$57.97
|
|
|
SURGICEL 2 X 3 (OXIDIZED C 1EA
|
Facility
|
IP
|
$65.88
|
|
| Hospital Charge Code |
27000225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$63.24 |
| Rate for Payer: Aetna Commercial |
$50.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.39
|
| Rate for Payer: Cash Price |
$32.94
|
| Rate for Payer: Cigna Commercial |
$54.68
|
| Rate for Payer: First Health Commercial |
$62.59
|
| Rate for Payer: Humana Commercial |
$56.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.97
|
| Rate for Payer: Ohio Health Group HMO |
$49.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.42
|
| Rate for Payer: PHCS Commercial |
$63.24
|
| Rate for Payer: United Healthcare All Payer |
$57.97
|
|
|
SURGICEL 2 X 3 (OXIDIZED C 1EA
|
Facility
|
IP
|
$76.51
|
|
|
Service Code
|
NDC 63713001953
|
| Hospital Charge Code |
27000225
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$73.45 |
| Rate for Payer: Aetna Commercial |
$58.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.68
|
| Rate for Payer: Cash Price |
$38.26
|
| Rate for Payer: Cigna Commercial |
$63.50
|
| Rate for Payer: First Health Commercial |
$72.68
|
| Rate for Payer: Humana Commercial |
$65.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.33
|
| Rate for Payer: Ohio Health Group HMO |
$57.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.72
|
| Rate for Payer: PHCS Commercial |
$73.45
|
| Rate for Payer: United Healthcare All Payer |
$67.33
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
OP
|
$141.34
|
|
|
Service Code
|
NDC 63713001952
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$135.69 |
| Rate for Payer: Aetna Commercial |
$108.83
|
| Rate for Payer: Anthem Medicaid |
$48.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.25
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cigna Commercial |
$117.31
|
| Rate for Payer: First Health Commercial |
$134.27
|
| Rate for Payer: Humana Commercial |
$120.14
|
| Rate for Payer: Humana KY Medicaid |
$48.61
|
| Rate for Payer: Kentucky WC Medicaid |
$49.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.38
|
| Rate for Payer: Ohio Health Group HMO |
$106.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.82
|
| Rate for Payer: PHCS Commercial |
$135.69
|
| Rate for Payer: United Healthcare All Payer |
$124.38
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
IP
|
$141.34
|
|
|
Service Code
|
NDC 63713001952
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.37 |
| Max. Negotiated Rate |
$135.69 |
| Rate for Payer: Aetna Commercial |
$108.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.25
|
| Rate for Payer: Cash Price |
$70.67
|
| Rate for Payer: Cigna Commercial |
$117.31
|
| Rate for Payer: First Health Commercial |
$134.27
|
| Rate for Payer: Humana Commercial |
$120.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.38
|
| Rate for Payer: Ohio Health Group HMO |
$106.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.82
|
| Rate for Payer: PHCS Commercial |
$135.69
|
| Rate for Payer: United Healthcare All Payer |
$124.38
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
IP
|
$121.57
|
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$116.71 |
| Rate for Payer: Aetna Commercial |
$93.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.82
|
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Cigna Commercial |
$100.90
|
| Rate for Payer: First Health Commercial |
$115.49
|
| Rate for Payer: Humana Commercial |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.98
|
| Rate for Payer: Ohio Health Group HMO |
$91.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.69
|
| Rate for Payer: PHCS Commercial |
$116.71
|
| Rate for Payer: United Healthcare All Payer |
$106.98
|
|
|
SURGICEL 4 X 8 (OXIDIZED C 1EA
|
Facility
|
OP
|
$121.57
|
|
| Hospital Charge Code |
27000223
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$116.71 |
| Rate for Payer: Aetna Commercial |
$93.61
|
| Rate for Payer: Anthem Medicaid |
$41.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.82
|
| Rate for Payer: Cash Price |
$60.78
|
| Rate for Payer: Cigna Commercial |
$100.90
|
| Rate for Payer: First Health Commercial |
$115.49
|
| Rate for Payer: Humana Commercial |
$103.33
|
| Rate for Payer: Humana KY Medicaid |
$41.81
|
| Rate for Payer: Kentucky WC Medicaid |
$42.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.98
|
| Rate for Payer: Ohio Health Group HMO |
$91.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.69
|
| Rate for Payer: PHCS Commercial |
$116.71
|
| Rate for Payer: United Healthcare All Payer |
$106.98
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
IP
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.11 |
| Max. Negotiated Rate |
$303.57 |
| Rate for Payer: Aetna Commercial |
$243.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.65
|
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Cigna Commercial |
$262.46
|
| Rate for Payer: First Health Commercial |
$300.41
|
| Rate for Payer: Humana Commercial |
$268.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$259.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$278.27
|
| Rate for Payer: Ohio Health Group HMO |
$237.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.03
|
| Rate for Payer: PHCS Commercial |
$303.57
|
| Rate for Payer: United Healthcare All Payer |
$278.27
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
OP
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.11 |
| Max. Negotiated Rate |
$303.57 |
| Rate for Payer: Aetna Commercial |
$243.49
|
| Rate for Payer: Anthem Medicaid |
$108.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$246.65
|
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Cigna Commercial |
$262.46
|
| Rate for Payer: First Health Commercial |
$300.41
|
| Rate for Payer: Humana Commercial |
$268.79
|
| Rate for Payer: Humana KY Medicaid |
$108.75
|
| Rate for Payer: Kentucky WC Medicaid |
$109.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$259.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$233.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$110.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$278.27
|
| Rate for Payer: Ohio Health Group HMO |
$237.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.03
|
| Rate for Payer: PHCS Commercial |
$303.57
|
| Rate for Payer: United Healthcare All Payer |
$278.27
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
OP
|
$350.78
|
|
|
Service Code
|
NDC 30120180
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$336.75 |
| Rate for Payer: Aetna Commercial |
$270.10
|
| Rate for Payer: Anthem Medicaid |
$120.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.61
|
| Rate for Payer: Cash Price |
$175.39
|
| Rate for Payer: Cigna Commercial |
$291.15
|
| Rate for Payer: First Health Commercial |
$333.24
|
| Rate for Payer: Humana Commercial |
$298.16
|
| Rate for Payer: Humana KY Medicaid |
$120.63
|
| Rate for Payer: Kentucky WC Medicaid |
$121.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.69
|
| Rate for Payer: Ohio Health Group HMO |
$263.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.74
|
| Rate for Payer: PHCS Commercial |
$336.75
|
| Rate for Payer: United Healthcare All Payer |
$308.69
|
|
|
SURGICEL POWDER 3GM PKG
|
Facility
|
IP
|
$350.78
|
|
|
Service Code
|
NDC 30120180
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$336.75 |
| Rate for Payer: Aetna Commercial |
$270.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.61
|
| Rate for Payer: Cash Price |
$175.39
|
| Rate for Payer: Cigna Commercial |
$291.15
|
| Rate for Payer: First Health Commercial |
$333.24
|
| Rate for Payer: Humana Commercial |
$298.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.69
|
| Rate for Payer: Ohio Health Group HMO |
$263.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.74
|
| Rate for Payer: PHCS Commercial |
$336.75
|
| Rate for Payer: United Healthcare All Payer |
$308.69
|
|
|
SURGICEL POWDER 3GM PKG
|
Professional
|
Both
|
$316.22
|
|
| Hospital Charge Code |
27000227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$110.68 |
| Max. Negotiated Rate |
$316.22 |
| Rate for Payer: Buckeye Medicare Advantage |
$316.22
|
| Rate for Payer: Cash Price |
$158.11
|
| Rate for Payer: Multiplan PHCS |
$189.73
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$221.35
|
| Rate for Payer: UHCCP Medicaid |
$110.68
|
|
