|
SURG STEEL MONO SUTURE 18*5
|
Facility
|
IP
|
$1,161.66
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.02 |
| Max. Negotiated Rate |
$1,115.19 |
| Rate for Payer: Aetna Commercial |
$894.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.09
|
| Rate for Payer: Cash Price |
$580.83
|
| Rate for Payer: Cigna Commercial |
$964.18
|
| Rate for Payer: First Health Commercial |
$1,103.58
|
| Rate for Payer: Humana Commercial |
$987.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.26
|
| Rate for Payer: Ohio Health Group HMO |
$871.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.11
|
| Rate for Payer: PHCS Commercial |
$1,115.19
|
| Rate for Payer: United Healthcare All Payer |
$1,022.26
|
|
|
SURG TREATMENT OF ANAL FISS
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 46270
|
| Hospital Charge Code |
76101922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.14 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$506.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$207.12
|
| Rate for Payer: Anthem Medicaid |
$162.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$452.11
|
| Rate for Payer: Healthspan PPO |
$532.60
|
| Rate for Payer: Humana Medicaid |
$162.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$475.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.38
|
| Rate for Payer: Molina Healthcare Passport |
$162.14
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$217.48
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$163.76
|
|
|
SURG TREATMENT OF ANAL FISS
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 46270
|
| Hospital Charge Code |
76101922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
SURG TREATMENT OF ANAL FISS
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 46270
|
| Hospital Charge Code |
76101922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$3,399.27 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,428.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,399.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,277.87
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,428.05
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,913.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
SURG TREATMENT OF ANAL FISS(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 46270
|
| Hospital Charge Code |
761P1922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.14 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$506.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$207.12
|
| Rate for Payer: Anthem Medicaid |
$162.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$452.11
|
| Rate for Payer: Healthspan PPO |
$532.60
|
| Rate for Payer: Humana Medicaid |
$162.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$475.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.38
|
| Rate for Payer: Molina Healthcare Passport |
$162.14
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$217.48
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$163.76
|
|
|
SURG VENT RESTORATION
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS 33548
|
| Hospital Charge Code |
76101312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
SURG VENT RESTORATION
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS 33548
|
| Hospital Charge Code |
76101312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
SURG VENT RESTORATION
|
Professional
|
Both
|
$5,000.00
|
|
|
Service Code
|
HCPCS 33548
|
| Hospital Charge Code |
76101312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,750.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Commercial |
$4,998.65
|
| Rate for Payer: Anthem Medicaid |
$1,763.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,000.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,622.60
|
| Rate for Payer: Healthspan PPO |
$4,914.65
|
| Rate for Payer: Humana Medicaid |
$1,763.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,214.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,798.29
|
| Rate for Payer: Molina Healthcare Passport |
$1,763.03
|
| Rate for Payer: Multiplan PHCS |
$3,000.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,500.00
|
| Rate for Payer: UHCCP Medicaid |
$1,750.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,780.66
|
|
|
SURG VENT RESTORATION(P
|
Professional
|
Both
|
$5,000.00
|
|
|
Service Code
|
HCPCS 33548
|
| Hospital Charge Code |
761P1312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,750.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Commercial |
$4,998.65
|
| Rate for Payer: Anthem Medicaid |
$1,763.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,000.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,622.60
|
| Rate for Payer: Healthspan PPO |
$4,914.65
|
| Rate for Payer: Humana Medicaid |
$1,763.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4,214.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,798.29
|
| Rate for Payer: Molina Healthcare Passport |
$1,763.03
|
| Rate for Payer: Multiplan PHCS |
$3,000.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,500.00
|
| Rate for Payer: UHCCP Medicaid |
$1,750.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,780.66
|
|
|
SURMONTIL 50MG CAPSULE
|
Facility
|
OP
|
$12.50
|
|
|
Service Code
|
NDC 51991094501
|
| Hospital Charge Code |
25001454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Anthem Medicaid |
$4.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.75
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$10.38
|
| Rate for Payer: First Health Commercial |
$11.88
|
| Rate for Payer: Humana Commercial |
$10.62
|
| Rate for Payer: Humana KY Medicaid |
$4.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.00
|
| Rate for Payer: Ohio Health Group HMO |
$9.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.88
|
| Rate for Payer: PHCS Commercial |
$12.00
|
| Rate for Payer: United Healthcare All Payer |
$11.00
|
|
|
SURMONTIL 50MG CAPSULE
|
Facility
|
IP
|
$12.50
|
|
|
Service Code
|
NDC 51991094501
|
| Hospital Charge Code |
25001454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.75
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$10.38
|
| Rate for Payer: First Health Commercial |
$11.88
|
| Rate for Payer: Humana Commercial |
$10.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.00
|
| Rate for Payer: Ohio Health Group HMO |
$9.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.88
|
| Rate for Payer: PHCS Commercial |
$12.00
|
| Rate for Payer: United Healthcare All Payer |
$11.00
|
|
|
SURMONTIL(TRIMIPRAMINE)25MGCAP
|
Facility
|
OP
|
$10.70
|
|
|
Service Code
|
NDC 51991094401
|
| Hospital Charge Code |
25001455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.27 |
| Rate for Payer: Aetna Commercial |
$8.24
|
| Rate for Payer: Anthem Medicaid |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: Cigna Commercial |
$8.88
|
| Rate for Payer: First Health Commercial |
$10.16
|
| Rate for Payer: Humana Commercial |
$9.10
|
| Rate for Payer: Humana KY Medicaid |
$3.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.42
|
| Rate for Payer: Ohio Health Group HMO |
$8.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$10.27
|
| Rate for Payer: United Healthcare All Payer |
$9.42
|
|
|
SURMONTIL(TRIMIPRAMINE)25MGCAP
|
Facility
|
IP
|
$10.70
|
|
|
Service Code
|
NDC 51991094401
|
| Hospital Charge Code |
25001455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.27 |
| Rate for Payer: Aetna Commercial |
$8.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Cash Price |
$5.35
|
| Rate for Payer: Cigna Commercial |
$8.88
|
| Rate for Payer: First Health Commercial |
$10.16
|
| Rate for Payer: Humana Commercial |
$9.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.42
|
| Rate for Payer: Ohio Health Group HMO |
$8.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.32
|
| Rate for Payer: PHCS Commercial |
$10.27
|
| Rate for Payer: United Healthcare All Payer |
$9.42
|
|
|
SUSCEPTIBILITY E TEST
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS 87181
|
| Hospital Charge Code |
30001318
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem Medicaid |
$12.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.75
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Humana KY Medicaid |
$12.04
|
| Rate for Payer: Humana Medicare Advantage |
$4.75
|
| Rate for Payer: Kentucky WC Medicaid |
$12.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
SUSCEPTIBILITY E TEST
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS 87181
|
| Hospital Charge Code |
30001318
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.10
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
SUSCEPTIBILITY STUDIES MIC
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
30001322
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.24
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
SUSCEPTIBILITY STUDIES MIC
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
30001322
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$13.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$7.67
|
| Rate for Payer: Healthspan PPO |
$8.09
|
| Rate for Payer: Multiplan PHCS |
$62.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.80
|
| Rate for Payer: UHCCP Medicaid |
$36.40
|
|
|
SUSCEPTIBILITY STUDIES MIC
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 87186
|
| Hospital Charge Code |
30001322
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem Medicaid |
$35.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.65
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Humana KY Medicaid |
$35.77
|
| Rate for Payer: Humana Medicare Advantage |
$8.65
|
| Rate for Payer: Kentucky WC Medicaid |
$36.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.24
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
SUSPENSION OF TESTIS
|
Facility
|
IP
|
$505.00
|
|
|
Service Code
|
HCPCS 54620
|
| Hospital Charge Code |
76102139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.65 |
| Max. Negotiated Rate |
$484.80 |
| Rate for Payer: Aetna Commercial |
$388.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.90
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$419.15
|
| Rate for Payer: First Health Commercial |
$479.75
|
| Rate for Payer: Humana Commercial |
$429.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$372.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$444.40
|
| Rate for Payer: Ohio Health Group HMO |
$378.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.55
|
| Rate for Payer: PHCS Commercial |
$484.80
|
| Rate for Payer: United Healthcare All Payer |
$444.40
|
|
|
SUSPENSION OF TESTIS
|
Facility
|
OP
|
$505.00
|
|
|
Service Code
|
HCPCS 54620
|
| Hospital Charge Code |
76102139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.65 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Aetna Commercial |
$388.85
|
| Rate for Payer: Anthem Medicaid |
$173.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$419.15
|
| Rate for Payer: First Health Commercial |
$479.75
|
| Rate for Payer: Humana Commercial |
$429.25
|
| Rate for Payer: Humana KY Medicaid |
$173.67
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$175.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$372.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$444.40
|
| Rate for Payer: Ohio Health Group HMO |
$378.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.55
|
| Rate for Payer: PHCS Commercial |
$484.80
|
| Rate for Payer: United Healthcare All Payer |
$444.40
|
|
|
SUSPENSION OF TESTIS
|
Professional
|
Both
|
$505.00
|
|
|
Service Code
|
HCPCS 54620
|
| Hospital Charge Code |
76102139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$176.75 |
| Max. Negotiated Rate |
$505.00 |
| Rate for Payer: Aetna Commercial |
$493.36
|
| Rate for Payer: Anthem Medicaid |
$234.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$505.00
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$441.03
|
| Rate for Payer: Healthspan PPO |
$477.69
|
| Rate for Payer: Humana Medicaid |
$234.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$409.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$239.38
|
| Rate for Payer: Molina Healthcare Passport |
$234.69
|
| Rate for Payer: Multiplan PHCS |
$303.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$353.50
|
| Rate for Payer: UHCCP Medicaid |
$176.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$237.04
|
|
|
SUSPENSION OF TESTIS(P
|
Professional
|
Both
|
$505.00
|
|
|
Service Code
|
HCPCS 54620
|
| Hospital Charge Code |
761P2139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$176.75 |
| Max. Negotiated Rate |
$505.00 |
| Rate for Payer: Aetna Commercial |
$493.36
|
| Rate for Payer: Anthem Medicaid |
$234.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$505.00
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cash Price |
$252.50
|
| Rate for Payer: Cigna Commercial |
$441.03
|
| Rate for Payer: Healthspan PPO |
$477.69
|
| Rate for Payer: Humana Medicaid |
$234.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$409.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$239.38
|
| Rate for Payer: Molina Healthcare Passport |
$234.69
|
| Rate for Payer: Multiplan PHCS |
$303.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$353.50
|
| Rate for Payer: UHCCP Medicaid |
$176.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$237.04
|
|
|
SUTR LG INT 1/MULT PERF W/COL
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 44605
|
| Hospital Charge Code |
76101857
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem Medicaid |
$722.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Humana KY Medicaid |
$722.19
|
| Rate for Payer: Kentucky WC Medicaid |
$729.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$736.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
SUTR LG INT 1/MULT PERF W/COL
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 44605
|
| Hospital Charge Code |
76101857
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$708.57 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$1,889.38
|
| Rate for Payer: Anthem Medicaid |
$708.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,100.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,767.81
|
| Rate for Payer: Healthspan PPO |
$1,593.35
|
| Rate for Payer: Humana Medicaid |
$708.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,671.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$722.74
|
| Rate for Payer: Molina Healthcare Passport |
$708.57
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,470.00
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$715.66
|
|
|
SUTR LG INT 1/MULT PERF W/COL
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 44605
|
| Hospital Charge Code |
76101857
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
