|
TINCTURE OF BENZOIN SPRAY 4OZ
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.18
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
TIROFIBAN 0.25mg (5mg SDBag)
|
Facility
|
IP
|
$476.33
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25004465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$457.28 |
| Rate for Payer: Aetna Commercial |
$366.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.54
|
| Rate for Payer: Cash Price |
$238.16
|
| Rate for Payer: Cigna Commercial |
$395.35
|
| Rate for Payer: First Health Commercial |
$452.51
|
| Rate for Payer: Humana Commercial |
$404.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$419.17
|
| Rate for Payer: Ohio Health Group HMO |
$357.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.67
|
| Rate for Payer: PHCS Commercial |
$457.28
|
| Rate for Payer: United Healthcare All Payer |
$419.17
|
|
|
TIROFIBAN 0.25mg (5mg SDBag)
|
Facility
|
OP
|
$476.33
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25004465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.90 |
| Max. Negotiated Rate |
$457.28 |
| Rate for Payer: Aetna Commercial |
$366.77
|
| Rate for Payer: Anthem Medicaid |
$163.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.54
|
| Rate for Payer: Cash Price |
$238.16
|
| Rate for Payer: Cigna Commercial |
$395.35
|
| Rate for Payer: First Health Commercial |
$452.51
|
| Rate for Payer: Humana Commercial |
$404.88
|
| Rate for Payer: Humana KY Medicaid |
$163.81
|
| Rate for Payer: Kentucky WC Medicaid |
$165.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$419.17
|
| Rate for Payer: Ohio Health Group HMO |
$357.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$414.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.67
|
| Rate for Payer: PHCS Commercial |
$457.28
|
| Rate for Payer: United Healthcare All Payer |
$419.17
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$289.80 |
| Max. Negotiated Rate |
$465.32 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem Medicaid |
$332.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$332.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$465.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$332.37
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Humana KY Medicaid |
$332.37
|
| Rate for Payer: Humana Medicare Advantage |
$332.37
|
| Rate for Payer: Kentucky WC Medicaid |
$335.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$398.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$339.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.80
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$335.76 |
| Rate for Payer: Aetna Commercial |
$317.09
|
| Rate for Payer: Ambetter Exchange |
$258.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$258.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$258.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$309.94
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$123.11
|
| Rate for Payer: Healthspan PPO |
$301.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$258.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.28
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$335.76
|
| Rate for Payer: UHCCP Medicaid |
$147.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$91.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$258.28
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.26
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.80
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
|
Facility
|
OP
|
$22,506.02
|
|
|
Service Code
|
CPT 19357
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$16,075.73 |
| Max. Negotiated Rate |
$22,506.02 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,075.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,506.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,702.24
|
| Rate for Payer: Humana Medicare Advantage |
$16,075.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,290.88
|
|
|
TISSUE EXPANDER RECTANGLE
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
TISSUE EXPANDER RECTANGLE
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
TISSUE HOMOGENIZATION
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 87176
|
| Hospital Charge Code |
30001315
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.22
|
| Rate for Payer: First Health Commercial |
$32.30
|
| Rate for Payer: Humana Commercial |
$28.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.92
|
| Rate for Payer: Ohio Health Group HMO |
$25.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.46
|
| Rate for Payer: PHCS Commercial |
$32.64
|
| Rate for Payer: United Healthcare All Payer |
$29.92
|
|
|
TISSUE HOMOGENIZATION
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS 87176
|
| Hospital Charge Code |
30001315
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Anthem Medicaid |
$5.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.88
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.22
|
| Rate for Payer: First Health Commercial |
$32.30
|
| Rate for Payer: Humana Commercial |
$28.90
|
| Rate for Payer: Humana KY Medicaid |
$5.88
|
| Rate for Payer: Humana Medicare Advantage |
$5.88
|
| Rate for Payer: Kentucky WC Medicaid |
$5.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.92
|
| Rate for Payer: Ohio Health Group HMO |
$25.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.46
|
| Rate for Payer: PHCS Commercial |
$32.64
|
| Rate for Payer: United Healthcare All Payer |
$29.92
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Professional
|
Both
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$22.04 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Commercial |
$150.04
|
| Rate for Payer: Ambetter Exchange |
$101.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$101.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$101.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.68
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$59.11
|
| Rate for Payer: Healthspan PPO |
$142.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$101.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.40
|
| Rate for Payer: Multiplan PHCS |
$265.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$131.82
|
| Rate for Payer: UHCCP Medicaid |
$154.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$101.40
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$158.33 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Professional
|
Both
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$874.10 |
| Max. Negotiated Rate |
$13,705.20 |
| Rate for Payer: Aetna Commercial |
$2,233.83
|
| Rate for Payer: Ambetter Exchange |
$1,092.60
|
| Rate for Payer: Anthem Medicaid |
$874.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,092.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,092.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,311.12
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$2,124.05
|
| Rate for Payer: Healthspan PPO |
$1,786.15
|
| Rate for Payer: Humana Medicaid |
$874.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,889.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,092.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,092.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$891.58
|
| Rate for Payer: Molina Healthcare Passport |
$874.10
|
| Rate for Payer: Multiplan PHCS |
$13,705.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,420.38
|
| Rate for Payer: UHCCP Medicaid |
$7,994.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$882.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,092.60
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Facility
|
OP
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$7,855.36 |
| Max. Negotiated Rate |
$22,506.02 |
| Rate for Payer: Aetna Commercial |
$17,588.34
|
| Rate for Payer: Anthem Medicaid |
$7,855.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,075.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,816.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,506.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,702.24
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$18,958.86
|
| Rate for Payer: First Health Commercial |
$21,699.90
|
| Rate for Payer: Humana Commercial |
$19,415.70
|
| Rate for Payer: Humana KY Medicaid |
$7,855.36
|
| Rate for Payer: Humana Medicare Advantage |
$16,075.73
|
| Rate for Payer: Kentucky WC Medicaid |
$7,935.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,730.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,857.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,290.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,012.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,100.96
|
| Rate for Payer: Ohio Health Group HMO |
$17,131.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,273.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,872.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,760.98
|
| Rate for Payer: PHCS Commercial |
$21,928.32
|
| Rate for Payer: United Healthcare All Payer |
$20,100.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Facility
|
IP
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,852.60 |
| Max. Negotiated Rate |
$21,928.32 |
| Rate for Payer: Aetna Commercial |
$17,588.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,816.76
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$18,958.86
|
| Rate for Payer: First Health Commercial |
$21,699.90
|
| Rate for Payer: Humana Commercial |
$19,415.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,730.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,857.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,852.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,100.96
|
| Rate for Payer: Ohio Health Group HMO |
$17,131.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,273.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,872.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,760.98
|
| Rate for Payer: PHCS Commercial |
$21,928.32
|
| Rate for Payer: United Healthcare All Payer |
$20,100.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761P0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$874.10 |
| Max. Negotiated Rate |
$2,233.83 |
| Rate for Payer: Aetna Commercial |
$2,233.83
|
| Rate for Payer: Ambetter Exchange |
$1,092.60
|
| Rate for Payer: Anthem Medicaid |
$874.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,092.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,092.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,311.12
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,124.05
|
| Rate for Payer: Healthspan PPO |
$1,786.15
|
| Rate for Payer: Humana Medicaid |
$874.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,889.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,092.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,092.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$891.58
|
| Rate for Payer: Molina Healthcare Passport |
$874.10
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,420.38
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$882.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,092.60
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (T
|
Facility
|
OP
|
$19,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761T0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,823.66 |
| Max. Negotiated Rate |
$22,506.02 |
| Rate for Payer: Aetna Commercial |
$15,278.34
|
| Rate for Payer: Anthem Medicaid |
$6,823.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,075.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,476.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,506.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,702.24
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cigna Commercial |
$16,468.86
|
| Rate for Payer: First Health Commercial |
$18,849.90
|
| Rate for Payer: Humana Commercial |
$16,865.70
|
| Rate for Payer: Humana KY Medicaid |
$6,823.66
|
| Rate for Payer: Humana Medicare Advantage |
$16,075.73
|
| Rate for Payer: Kentucky WC Medicaid |
$6,893.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,643.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,290.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,960.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,460.96
|
| Rate for Payer: Ohio Health Group HMO |
$14,881.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,873.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,262.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,690.98
|
| Rate for Payer: PHCS Commercial |
$19,048.32
|
| Rate for Payer: United Healthcare All Payer |
$17,460.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (T
|
Facility
|
IP
|
$19,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761T0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$5,952.60 |
| Max. Negotiated Rate |
$19,048.32 |
| Rate for Payer: Aetna Commercial |
$15,278.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,476.76
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cigna Commercial |
$16,468.86
|
| Rate for Payer: First Health Commercial |
$18,849.90
|
| Rate for Payer: Humana Commercial |
$16,865.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,643.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,952.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,460.96
|
| Rate for Payer: Ohio Health Group HMO |
$14,881.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,873.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,262.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,690.98
|
| Rate for Payer: PHCS Commercial |
$19,048.32
|
| Rate for Payer: United Healthcare All Payer |
$17,460.96
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Professional
|
Both
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.02 |
| Max. Negotiated Rate |
$2,079.98 |
| Rate for Payer: Aetna Commercial |
$357.37
|
| Rate for Payer: Ambetter Exchange |
$202.82
|
| Rate for Payer: Anthem Medicaid |
$169.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$243.38
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$360.42
|
| Rate for Payer: Healthspan PPO |
$224.81
|
| Rate for Payer: Humana Medicaid |
$169.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.40
|
| Rate for Payer: Molina Healthcare Passport |
$169.02
|
| Rate for Payer: Multiplan PHCS |
$2,079.98
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.67
|
| Rate for Payer: UHCCP Medicaid |
$1,213.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.82
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Facility
|
OP
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,039.99 |
| Max. Negotiated Rate |
$3,327.96 |
| Rate for Payer: Aetna Commercial |
$2,669.31
|
| Rate for Payer: Anthem Medicaid |
$1,192.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,703.97
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$2,877.30
|
| Rate for Payer: First Health Commercial |
$3,293.30
|
| Rate for Payer: Humana Commercial |
$2,946.64
|
| Rate for Payer: Humana KY Medicaid |
$1,192.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,204.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,842.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,558.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,216.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,050.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,599.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,773.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,015.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,391.97
|
| Rate for Payer: PHCS Commercial |
$3,327.96
|
| Rate for Payer: United Healthcare All Payer |
$3,050.63
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Facility
|
IP
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,039.99 |
| Max. Negotiated Rate |
$3,327.96 |
| Rate for Payer: Aetna Commercial |
$2,669.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,703.97
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$2,877.30
|
| Rate for Payer: First Health Commercial |
$3,293.30
|
| Rate for Payer: Humana Commercial |
$2,946.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,842.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,558.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,050.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,599.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,773.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,015.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,391.97
|
| Rate for Payer: PHCS Commercial |
$3,327.96
|
| Rate for Payer: United Healthcare All Payer |
$3,050.63
|
|
|
TIS TRNFR ADDL 30 SQ CM(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
761P0170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.02 |
| Max. Negotiated Rate |
$360.42 |
| Rate for Payer: Aetna Commercial |
$357.37
|
| Rate for Payer: Ambetter Exchange |
$202.82
|
| Rate for Payer: Anthem Medicaid |
$169.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$202.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$202.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$243.38
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$360.42
|
| Rate for Payer: Healthspan PPO |
$224.81
|
| Rate for Payer: Humana Medicaid |
$169.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$202.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.40
|
| Rate for Payer: Molina Healthcare Passport |
$169.02
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$263.67
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$202.82
|
|
|
TIS TRNFR ADDL 30 SQ CM(T
|
Facility
|
OP
|
$2,966.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
761T0170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$889.99 |
| Max. Negotiated Rate |
$2,847.96 |
| Rate for Payer: Aetna Commercial |
$2,284.31
|
| Rate for Payer: Anthem Medicaid |
$1,020.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,313.97
|
| Rate for Payer: Cash Price |
$1,483.32
|
| Rate for Payer: Cigna Commercial |
$2,462.30
|
| Rate for Payer: First Health Commercial |
$2,818.30
|
| Rate for Payer: Humana Commercial |
$2,521.64
|
| Rate for Payer: Humana KY Medicaid |
$1,020.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,030.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,432.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,189.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$889.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,040.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,610.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,224.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,373.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,580.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,046.97
|
| Rate for Payer: PHCS Commercial |
$2,847.96
|
| Rate for Payer: United Healthcare All Payer |
$2,610.63
|
|
