|
CHANGE OF WINDPIPE AIRWAY(P
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
410P0014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Anthem Medicaid |
$36.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$70.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| 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 |
$42.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.00
|
| Rate for Payer: UHCCP Medicaid |
$24.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.69
|
|
|
CHANGE OF WINDPIPE AIRWAY(T
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
410T0014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$93.47 |
| Max. Negotiated Rate |
$690.24 |
| Rate for Payer: Aetna Commercial |
$553.63
|
| Rate for Payer: Anthem Medicaid |
$247.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$560.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$285.16
|
| Rate for Payer: Cash Price |
$359.50
|
| Rate for Payer: Cash Price |
$359.50
|
| Rate for Payer: Cigna Commercial |
$596.77
|
| Rate for Payer: First Health Commercial |
$683.05
|
| Rate for Payer: Humana Commercial |
$611.15
|
| Rate for Payer: Humana KY Medicaid |
$247.26
|
| Rate for Payer: Humana Medicare Advantage |
$211.23
|
| Rate for Payer: Kentucky WC Medicaid |
$249.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$589.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$530.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$252.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$632.72
|
| Rate for Payer: Ohio Health Group HMO |
$539.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.89
|
| Rate for Payer: PHCS Commercial |
$690.24
|
| Rate for Payer: United Healthcare All Payer |
$632.72
|
|
|
CHANGE OF WINDPIPE AIRWAY(T
|
Facility
|
IP
|
$719.00
|
|
|
Service Code
|
HCPCS 31502
|
| Hospital Charge Code |
410T0014
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$93.47 |
| Max. Negotiated Rate |
$690.24 |
| Rate for Payer: Aetna Commercial |
$553.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$560.82
|
| Rate for Payer: Cash Price |
$359.50
|
| Rate for Payer: Cigna Commercial |
$596.77
|
| Rate for Payer: First Health Commercial |
$683.05
|
| Rate for Payer: Humana Commercial |
$611.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$589.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$530.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$215.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$632.72
|
| Rate for Payer: Ohio Health Group HMO |
$539.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.89
|
| Rate for Payer: PHCS Commercial |
$690.24
|
| Rate for Payer: United Healthcare All Payer |
$632.72
|
|
|
CHANTIX (VARENICLINE)0.5MG TAB
|
Facility
|
IP
|
$5.18
|
|
|
Service Code
|
NDC 49884015576
|
| Hospital Charge Code |
25000411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$3.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.04
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cigna Commercial |
$4.30
|
| Rate for Payer: First Health Commercial |
$4.92
|
| Rate for Payer: Humana Commercial |
$4.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.56
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.97
|
| Rate for Payer: United Healthcare All Payer |
$4.56
|
|
|
CHANTIX (VARENICLINE)0.5MG TAB
|
Facility
|
OP
|
$5.18
|
|
|
Service Code
|
NDC 49884015576
|
| Hospital Charge Code |
25000411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna Commercial |
$3.99
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.04
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cigna Commercial |
$4.30
|
| Rate for Payer: First Health Commercial |
$4.92
|
| Rate for Payer: Humana Commercial |
$4.40
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.56
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.97
|
| Rate for Payer: United Healthcare All Payer |
$4.56
|
|
|
CHARCOCAP(ACTIVATED 260MG/1CAP
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 89411043110
|
| Hospital Charge Code |
25000413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
CHARCOCAP(ACTIVATED 260MG/1CAP
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 89411043110
|
| Hospital Charge Code |
25000413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
CHECK FLO INTRODUCER LG 16F
|
Facility
|
IP
|
$1,810.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.31 |
| Max. Negotiated Rate |
$1,737.68 |
| Rate for Payer: Aetna Commercial |
$1,393.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.86
|
| Rate for Payer: Cash Price |
$905.04
|
| Rate for Payer: Cigna Commercial |
$1,502.37
|
| Rate for Payer: First Health Commercial |
$1,719.58
|
| Rate for Payer: Humana Commercial |
$1,538.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.12
|
| Rate for Payer: PHCS Commercial |
$1,737.68
|
| Rate for Payer: United Healthcare All Payer |
$1,592.87
|
|
|
CHECK FLO INTRODUCER LG 16F
|
Facility
|
OP
|
$1,810.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.31 |
| Max. Negotiated Rate |
$1,737.68 |
| Rate for Payer: Aetna Commercial |
$1,393.76
|
| Rate for Payer: Anthem Medicaid |
$622.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.86
|
| Rate for Payer: Cash Price |
$905.04
|
| Rate for Payer: Cigna Commercial |
$1,502.37
|
| Rate for Payer: First Health Commercial |
$1,719.58
|
| Rate for Payer: Humana Commercial |
$1,538.57
|
| Rate for Payer: Humana KY Medicaid |
$622.49
|
| Rate for Payer: Kentucky WC Medicaid |
$628.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.12
|
| Rate for Payer: PHCS Commercial |
$1,737.68
|
| Rate for Payer: United Healthcare All Payer |
$1,592.87
|
|
|
CHECK FLO INTRODUCER LG 18F
|
Facility
|
OP
|
$1,810.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.31 |
| Max. Negotiated Rate |
$1,737.68 |
| Rate for Payer: Aetna Commercial |
$1,393.76
|
| Rate for Payer: Anthem Medicaid |
$622.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.86
|
| Rate for Payer: Cash Price |
$905.04
|
| Rate for Payer: Cigna Commercial |
$1,502.37
|
| Rate for Payer: First Health Commercial |
$1,719.58
|
| Rate for Payer: Humana Commercial |
$1,538.57
|
| Rate for Payer: Humana KY Medicaid |
$622.49
|
| Rate for Payer: Kentucky WC Medicaid |
$628.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.12
|
| Rate for Payer: PHCS Commercial |
$1,737.68
|
| Rate for Payer: United Healthcare All Payer |
$1,592.87
|
|
|
CHECK FLO INTRODUCER LG 18F
|
Facility
|
IP
|
$1,810.08
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.31 |
| Max. Negotiated Rate |
$1,737.68 |
| Rate for Payer: Aetna Commercial |
$1,393.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,411.86
|
| Rate for Payer: Cash Price |
$905.04
|
| Rate for Payer: Cigna Commercial |
$1,502.37
|
| Rate for Payer: First Health Commercial |
$1,719.58
|
| Rate for Payer: Humana Commercial |
$1,538.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,484.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,335.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,592.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,357.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.12
|
| Rate for Payer: PHCS Commercial |
$1,737.68
|
| Rate for Payer: United Healthcare All Payer |
$1,592.87
|
|
|
CHECK FLO INTRODUCER LG 20F
|
Facility
|
OP
|
$3,421.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.80 |
| Max. Negotiated Rate |
$3,284.64 |
| Rate for Payer: Aetna Commercial |
$2,634.56
|
| Rate for Payer: Anthem Medicaid |
$1,176.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,668.77
|
| Rate for Payer: Cash Price |
$1,710.75
|
| Rate for Payer: Cigna Commercial |
$2,839.84
|
| Rate for Payer: First Health Commercial |
$3,250.42
|
| Rate for Payer: Humana Commercial |
$2,908.28
|
| Rate for Payer: Humana KY Medicaid |
$1,176.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,188.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,805.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,525.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,026.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,200.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,010.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,566.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$444.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,060.66
|
| Rate for Payer: PHCS Commercial |
$3,284.64
|
| Rate for Payer: United Healthcare All Payer |
$3,010.92
|
|
|
CHECK FLO INTRODUCER LG 20F
|
Facility
|
IP
|
$3,421.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$444.80 |
| Max. Negotiated Rate |
$3,284.64 |
| Rate for Payer: Aetna Commercial |
$2,634.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,668.77
|
| Rate for Payer: Cash Price |
$1,710.75
|
| Rate for Payer: Cigna Commercial |
$2,839.84
|
| Rate for Payer: First Health Commercial |
$3,250.42
|
| Rate for Payer: Humana Commercial |
$2,908.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,805.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,525.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,026.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,010.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,566.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$444.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,060.66
|
| Rate for Payer: PHCS Commercial |
$3,284.64
|
| Rate for Payer: United Healthcare All Payer |
$3,010.92
|
|
|
Cheeks Laser Hair Removal
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200216
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
Cheeks LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200217
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$319.00
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
Cheeks LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$159.00
|
|
| Hospital Charge Code |
22200474
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
|
|
CHEM CAUT GRANULATION TISS
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
45000082
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem Medicaid |
$92.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Humana KY Medicaid |
$92.85
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$93.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.70
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
CHEM CAUT GRANULATION TISS
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
76100253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| 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 |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
CHEM CAUT GRANULATION TISS
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
45000082
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.70
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
CHEM CAUT GRANULATION TISS
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
76100253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$52.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.41
|
| Rate for Payer: Anthem Medicaid |
$20.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$98.89
|
| Rate for Payer: Healthspan PPO |
$81.27
|
| Rate for Payer: Humana Medicaid |
$20.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.60
|
| Rate for Payer: Molina Healthcare Passport |
$20.20
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$294.00
|
| Rate for Payer: UHCCP Medicaid |
$21.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.40
|
|
|
CHEM CAUT GRANULATION TISS
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
76100253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem Medicaid |
$144.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| 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 |
$144.44
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$145.91
|
| 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 |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.34
|
| 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 |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
CHEM CAUT GRANULATION TISS(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
761P0253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$52.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.41
|
| Rate for Payer: Anthem Medicaid |
$20.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$98.89
|
| Rate for Payer: Healthspan PPO |
$81.27
|
| Rate for Payer: Humana Medicaid |
$20.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.60
|
| Rate for Payer: Molina Healthcare Passport |
$20.20
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$21.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.40
|
|
|
CHEM CAUT GRANULATION TISS(T
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
761T0253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.70
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
CHEM CAUT GRANULATION TISS(T
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS 17250
|
| Hospital Charge Code |
761T0253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem Medicaid |
$92.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Humana KY Medicaid |
$92.85
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$93.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.70
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
CHEMICAL PEEL - BACK
|
Professional
|
Both
|
$150.00
|
|
| Hospital Charge Code |
22200326
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
