|
[C]GUAIF/COD 5ML PO
|
Facility
|
IP
|
$60.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$57.93 |
| Rate for Payer: Aetna Commercial |
$46.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Cash Price |
$30.17
|
| Rate for Payer: Cigna Commercial |
$50.08
|
| Rate for Payer: First Health Commercial |
$57.32
|
| Rate for Payer: Humana Commercial |
$51.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.10
|
| Rate for Payer: Ohio Health Group HMO |
$45.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$57.93
|
| Rate for Payer: United Healthcare All Payer |
$53.10
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Professional
|
Both
|
$997.11
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$997.11 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.35
|
| Rate for Payer: Anthem Medicaid |
$35.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$997.11
|
| Rate for Payer: Cash Price |
$498.56
|
| Rate for Payer: Cash Price |
$498.56
|
| Rate for Payer: Cigna Commercial |
$180.74
|
| Rate for Payer: Healthspan PPO |
$140.98
|
| Rate for Payer: Humana Medicaid |
$35.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.82
|
| Rate for Payer: Molina Healthcare Passport |
$35.12
|
| Rate for Payer: Multiplan PHCS |
$598.27
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$697.98
|
| Rate for Payer: UHCCP Medicaid |
$39.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.47
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
IP
|
$997.11
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.62 |
| Max. Negotiated Rate |
$957.23 |
| Rate for Payer: Aetna Commercial |
$767.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.75
|
| Rate for Payer: Cash Price |
$498.56
|
| Rate for Payer: Cigna Commercial |
$827.60
|
| Rate for Payer: First Health Commercial |
$947.25
|
| Rate for Payer: Humana Commercial |
$847.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$299.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.46
|
| Rate for Payer: Ohio Health Group HMO |
$747.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$199.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$309.10
|
| Rate for Payer: PHCS Commercial |
$957.23
|
| Rate for Payer: United Healthcare All Payer |
$877.46
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
45000282
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
OP
|
$997.11
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.62 |
| Max. Negotiated Rate |
$957.23 |
| Rate for Payer: Aetna Commercial |
$767.77
|
| Rate for Payer: Anthem Medicaid |
$342.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$498.56
|
| Rate for Payer: Cash Price |
$498.56
|
| Rate for Payer: Cigna Commercial |
$827.60
|
| Rate for Payer: First Health Commercial |
$947.25
|
| Rate for Payer: Humana Commercial |
$847.54
|
| Rate for Payer: Humana KY Medicaid |
$342.91
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$346.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$349.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.46
|
| Rate for Payer: Ohio Health Group HMO |
$747.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$199.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$309.10
|
| Rate for Payer: PHCS Commercial |
$957.23
|
| Rate for Payer: United Healthcare All Payer |
$877.46
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
45000282
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem Medicaid |
$120.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Humana KY Medicaid |
$120.36
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$121.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761P2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.12 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.35
|
| Rate for Payer: Anthem Medicaid |
$35.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$180.74
|
| Rate for Payer: Healthspan PPO |
$140.98
|
| Rate for Payer: Humana Medicaid |
$35.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.82
|
| Rate for Payer: Molina Healthcare Passport |
$35.12
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$39.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.47
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(T
|
Facility
|
OP
|
$797.11
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761T2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.62 |
| Max. Negotiated Rate |
$765.23 |
| Rate for Payer: Aetna Commercial |
$613.77
|
| Rate for Payer: Anthem Medicaid |
$274.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$398.56
|
| Rate for Payer: Cash Price |
$398.56
|
| Rate for Payer: Cigna Commercial |
$661.60
|
| Rate for Payer: First Health Commercial |
$757.25
|
| Rate for Payer: Humana Commercial |
$677.54
|
| Rate for Payer: Humana KY Medicaid |
$274.13
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$276.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$279.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.46
|
| Rate for Payer: Ohio Health Group HMO |
$597.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.10
|
| Rate for Payer: PHCS Commercial |
$765.23
|
| Rate for Payer: United Healthcare All Payer |
$701.46
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(T
|
Facility
|
IP
|
$797.11
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761T2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.62 |
| Max. Negotiated Rate |
$765.23 |
| Rate for Payer: Aetna Commercial |
$613.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.75
|
| Rate for Payer: Cash Price |
$398.56
|
| Rate for Payer: Cigna Commercial |
$661.60
|
| Rate for Payer: First Health Commercial |
$757.25
|
| Rate for Payer: Humana Commercial |
$677.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.46
|
| Rate for Payer: Ohio Health Group HMO |
$597.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.10
|
| Rate for Payer: PHCS Commercial |
$765.23
|
| Rate for Payer: United Healthcare All Payer |
$701.46
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Professional
|
Both
|
$545.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761P2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$545.00 |
| Rate for Payer: Aetna Commercial |
$153.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.24
|
| Rate for Payer: Anthem Medicaid |
$51.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$545.00
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$261.29
|
| Rate for Payer: Healthspan PPO |
$199.18
|
| Rate for Payer: Humana Medicaid |
$51.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.98
|
| Rate for Payer: Molina Healthcare Passport |
$51.94
|
| Rate for Payer: Multiplan PHCS |
$327.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$381.50
|
| Rate for Payer: UHCCP Medicaid |
$65.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.46
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Professional
|
Both
|
$2,577.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$2,577.00 |
| Rate for Payer: Aetna Commercial |
$153.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.24
|
| Rate for Payer: Anthem Medicaid |
$51.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,577.00
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cigna Commercial |
$261.29
|
| Rate for Payer: Healthspan PPO |
$199.18
|
| Rate for Payer: Humana Medicaid |
$51.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.98
|
| Rate for Payer: Molina Healthcare Passport |
$51.94
|
| Rate for Payer: Multiplan PHCS |
$1,546.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,803.90
|
| Rate for Payer: UHCCP Medicaid |
$65.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.46
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
OP
|
$2,577.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$335.01 |
| Max. Negotiated Rate |
$2,473.92 |
| Rate for Payer: Aetna Commercial |
$1,984.29
|
| Rate for Payer: Anthem Medicaid |
$886.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cigna Commercial |
$2,138.91
|
| Rate for Payer: First Health Commercial |
$2,448.15
|
| Rate for Payer: Humana Commercial |
$2,190.45
|
| Rate for Payer: Humana KY Medicaid |
$886.23
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$895.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,901.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$904.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,267.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,932.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$515.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$335.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$798.87
|
| Rate for Payer: PHCS Commercial |
$2,473.92
|
| Rate for Payer: United Healthcare All Payer |
$2,267.76
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
IP
|
$2,577.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$335.01 |
| Max. Negotiated Rate |
$2,473.92 |
| Rate for Payer: Aetna Commercial |
$1,984.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.06
|
| Rate for Payer: Cash Price |
$1,288.50
|
| Rate for Payer: Cigna Commercial |
$2,138.91
|
| Rate for Payer: First Health Commercial |
$2,448.15
|
| Rate for Payer: Humana Commercial |
$2,190.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,901.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$773.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,267.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,932.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$515.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$335.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$798.87
|
| Rate for Payer: PHCS Commercial |
$2,473.92
|
| Rate for Payer: United Healthcare All Payer |
$2,267.76
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
IP
|
$2,032.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761T2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.16 |
| Max. Negotiated Rate |
$1,950.72 |
| Rate for Payer: Aetna Commercial |
$1,564.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,584.96
|
| Rate for Payer: Cash Price |
$1,016.00
|
| Rate for Payer: Cigna Commercial |
$1,686.56
|
| Rate for Payer: First Health Commercial |
$1,930.40
|
| Rate for Payer: Humana Commercial |
$1,727.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$629.92
|
| Rate for Payer: PHCS Commercial |
$1,950.72
|
| Rate for Payer: United Healthcare All Payer |
$1,788.16
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
OP
|
$2,032.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761T2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.16 |
| Max. Negotiated Rate |
$1,950.72 |
| Rate for Payer: Aetna Commercial |
$1,564.64
|
| Rate for Payer: Anthem Medicaid |
$698.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$590.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,584.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$827.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$797.47
|
| Rate for Payer: Cash Price |
$1,016.00
|
| Rate for Payer: Cash Price |
$1,016.00
|
| Rate for Payer: Cigna Commercial |
$1,686.56
|
| Rate for Payer: First Health Commercial |
$1,930.40
|
| Rate for Payer: Humana Commercial |
$1,727.20
|
| Rate for Payer: Humana KY Medicaid |
$698.80
|
| Rate for Payer: Humana Medicare Advantage |
$590.72
|
| Rate for Payer: Kentucky WC Medicaid |
$705.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$708.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$712.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$629.92
|
| Rate for Payer: PHCS Commercial |
$1,950.72
|
| Rate for Payer: United Healthcare All Payer |
$1,788.16
|
|
|
CHANGE OF CYSTOSTOMY TUBE; SIMPLE
|
Facility
|
OP
|
$299.21
|
|
|
Service Code
|
CPT 51705
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$213.72 |
| Max. Negotiated Rate |
$299.21 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
|
|
CHANGE OF URETER TUBE/STENT
|
Facility
|
OP
|
$3,635.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
761T2771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$472.55 |
| Max. Negotiated Rate |
$3,489.60 |
| Rate for Payer: Aetna Commercial |
$2,798.95
|
| Rate for Payer: Anthem Medicaid |
$1,250.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,761.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,835.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,465.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,377.81
|
| Rate for Payer: Cash Price |
$1,817.50
|
| Rate for Payer: Cash Price |
$1,817.50
|
| Rate for Payer: Cigna Commercial |
$3,017.05
|
| Rate for Payer: First Health Commercial |
$3,453.25
|
| Rate for Payer: Humana Commercial |
$3,089.75
|
| Rate for Payer: Humana KY Medicaid |
$1,250.08
|
| Rate for Payer: Humana Medicare Advantage |
$1,761.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,262.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,980.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,682.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,275.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,198.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,726.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.85
|
| Rate for Payer: PHCS Commercial |
$3,489.60
|
| Rate for Payer: United Healthcare All Payer |
$3,198.80
|
|
|
CHANGE OF URETER TUBE/STENT
|
Facility
|
IP
|
$3,635.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
761T2771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$472.55 |
| Max. Negotiated Rate |
$3,489.60 |
| Rate for Payer: Aetna Commercial |
$2,798.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,835.30
|
| Rate for Payer: Cash Price |
$1,817.50
|
| Rate for Payer: Cigna Commercial |
$3,017.05
|
| Rate for Payer: First Health Commercial |
$3,453.25
|
| Rate for Payer: Humana Commercial |
$3,089.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,980.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,682.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,090.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,198.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,726.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.85
|
| Rate for Payer: PHCS Commercial |
$3,489.60
|
| Rate for Payer: United Healthcare All Payer |
$3,198.80
|
|
|
CHANGE OF URETER TUBE/STENT
|
Facility
|
OP
|
$3,735.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
76102771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$485.55 |
| Max. Negotiated Rate |
$3,585.60 |
| Rate for Payer: Aetna Commercial |
$2,875.95
|
| Rate for Payer: Anthem Medicaid |
$1,284.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,761.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,913.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,465.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,377.81
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$3,100.05
|
| Rate for Payer: First Health Commercial |
$3,548.25
|
| Rate for Payer: Humana Commercial |
$3,174.75
|
| Rate for Payer: Humana KY Medicaid |
$1,284.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,761.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,297.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,062.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,756.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,310.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,286.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,801.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,157.85
|
| Rate for Payer: PHCS Commercial |
$3,585.60
|
| Rate for Payer: United Healthcare All Payer |
$3,286.80
|
|
|
CHANGE OF URETER TUBE/STENT
|
Professional
|
Both
|
$3,735.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
76102771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$3,735.00 |
| Rate for Payer: Aetna Commercial |
$127.17
|
| Rate for Payer: Anthem Medicaid |
$44.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,735.00
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$122.23
|
| Rate for Payer: Healthspan PPO |
$101.68
|
| Rate for Payer: Humana Medicaid |
$44.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.78
|
| Rate for Payer: Molina Healthcare Passport |
$44.88
|
| Rate for Payer: Multiplan PHCS |
$2,241.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,614.50
|
| Rate for Payer: UHCCP Medicaid |
$1,307.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.33
|
|
|
CHANGE OF URETER TUBE/STENT
|
Facility
|
IP
|
$3,735.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
76102771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$485.55 |
| Max. Negotiated Rate |
$3,585.60 |
| Rate for Payer: Aetna Commercial |
$2,875.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,913.30
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$3,100.05
|
| Rate for Payer: First Health Commercial |
$3,548.25
|
| Rate for Payer: Humana Commercial |
$3,174.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,062.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,756.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,120.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,286.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,801.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,157.85
|
| Rate for Payer: PHCS Commercial |
$3,585.60
|
| Rate for Payer: United Healthcare All Payer |
$3,286.80
|
|
|
CHANGE OF URETER TUBE/STENT
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
761P2771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$127.17 |
| Rate for Payer: Aetna Commercial |
$127.17
|
| Rate for Payer: Anthem Medicaid |
$44.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$122.23
|
| Rate for Payer: Healthspan PPO |
$101.68
|
| Rate for Payer: Humana Medicaid |
$44.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.78
|
| Rate for Payer: Molina Healthcare Passport |
$44.88
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.33
|
|
|
CHANGE OF WINDPIPE AIRWAY
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
41000014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$102.57 |
| Max. Negotiated Rate |
$757.44 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem Medicaid |
$271.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$285.16
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Humana KY Medicaid |
$271.34
|
| Rate for Payer: Humana Medicare Advantage |
$211.23
|
| Rate for Payer: Kentucky WC Medicaid |
$274.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$276.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.59
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
CHANGE OF WINDPIPE AIRWAY
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
41000014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$102.57 |
| Max. Negotiated Rate |
$757.44 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$236.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.59
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
CHANGE OF WINDPIPE AIRWAY
|
Professional
|
Both
|
$789.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
41000014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$36.33 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Anthem Medicaid |
$36.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$789.00
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$52.75
|
| Rate for Payer: Healthspan PPO |
$45.48
|
| Rate for Payer: Humana Medicaid |
$36.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.06
|
| Rate for Payer: Molina Healthcare Passport |
$36.33
|
| Rate for Payer: Multiplan PHCS |
$473.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$552.30
|
| Rate for Payer: UHCCP Medicaid |
$276.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.69
|
|
