|
CHEMODENERV 1 EXTREM 5/> EA(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 64645
|
| Hospital Charge Code |
761P2354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$63.28 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$63.28
|
| Rate for Payer: Anthem Medicaid |
$65.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$189.42
|
| Rate for Payer: Healthspan PPO |
$149.57
|
| Rate for Payer: Humana Medicaid |
$65.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$106.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.63
|
| Rate for Payer: Molina Healthcare Passport |
$65.32
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$66.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.97
|
|
|
CHEMODENERV 1 EXTREM 5/> EA(T
|
Facility
|
OP
|
$521.00
|
|
|
Service Code
|
HCPCS 64645
|
| Hospital Charge Code |
761T2354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.73 |
| Max. Negotiated Rate |
$500.16 |
| Rate for Payer: Aetna Commercial |
$401.17
|
| Rate for Payer: Anthem Medicaid |
$179.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$406.38
|
| Rate for Payer: Cash Price |
$260.50
|
| Rate for Payer: Cigna Commercial |
$432.43
|
| Rate for Payer: First Health Commercial |
$494.95
|
| Rate for Payer: Humana Commercial |
$442.85
|
| Rate for Payer: Humana KY Medicaid |
$179.17
|
| Rate for Payer: Kentucky WC Medicaid |
$181.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$427.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$384.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$458.48
|
| Rate for Payer: Ohio Health Group HMO |
$390.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.51
|
| Rate for Payer: PHCS Commercial |
$500.16
|
| Rate for Payer: United Healthcare All Payer |
$458.48
|
|
|
CHEMODENERV 1 EXTREM 5/> EA(T
|
Facility
|
IP
|
$521.00
|
|
|
Service Code
|
HCPCS 64645
|
| Hospital Charge Code |
761T2354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.73 |
| Max. Negotiated Rate |
$500.16 |
| Rate for Payer: Aetna Commercial |
$401.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$406.38
|
| Rate for Payer: Cash Price |
$260.50
|
| Rate for Payer: Cigna Commercial |
$432.43
|
| Rate for Payer: First Health Commercial |
$494.95
|
| Rate for Payer: Humana Commercial |
$442.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$427.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$384.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$458.48
|
| Rate for Payer: Ohio Health Group HMO |
$390.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.51
|
| Rate for Payer: PHCS Commercial |
$500.16
|
| Rate for Payer: United Healthcare All Payer |
$458.48
|
|
|
CHEMODENERV 1 EXTREM 5/> MU(P
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
761P2353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.37 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.88
|
| Rate for Payer: Anthem Medicaid |
$92.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.00
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$267.96
|
| Rate for Payer: Healthspan PPO |
$211.18
|
| Rate for Payer: Humana Medicaid |
$92.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.22
|
| Rate for Payer: Molina Healthcare Passport |
$92.37
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$98.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.29
|
|
|
CHEMODENERV 1 EXTREM 5/> MUS
|
Facility
|
OP
|
$1,258.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
76102353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.54 |
| Max. Negotiated Rate |
$1,207.68 |
| Rate for Payer: Aetna Commercial |
$968.66
|
| Rate for Payer: Anthem Medicaid |
$432.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$981.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$629.00
|
| Rate for Payer: Cash Price |
$629.00
|
| Rate for Payer: Cigna Commercial |
$1,044.14
|
| Rate for Payer: First Health Commercial |
$1,195.10
|
| Rate for Payer: Humana Commercial |
$1,069.30
|
| Rate for Payer: Humana KY Medicaid |
$432.63
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$437.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,031.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$928.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$441.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,107.04
|
| Rate for Payer: Ohio Health Group HMO |
$943.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.98
|
| Rate for Payer: PHCS Commercial |
$1,207.68
|
| Rate for Payer: United Healthcare All Payer |
$1,107.04
|
|
|
CHEMODENERV 1 EXTREM 5/> MUS
|
Facility
|
IP
|
$1,258.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
76102353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.54 |
| Max. Negotiated Rate |
$1,207.68 |
| Rate for Payer: Aetna Commercial |
$968.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$981.24
|
| Rate for Payer: Cash Price |
$629.00
|
| Rate for Payer: Cigna Commercial |
$1,044.14
|
| Rate for Payer: First Health Commercial |
$1,195.10
|
| Rate for Payer: Humana Commercial |
$1,069.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,031.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$928.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$377.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,107.04
|
| Rate for Payer: Ohio Health Group HMO |
$943.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.98
|
| Rate for Payer: PHCS Commercial |
$1,207.68
|
| Rate for Payer: United Healthcare All Payer |
$1,107.04
|
|
|
CHEMODENERV 1 EXTREM 5/> MUS
|
Professional
|
Both
|
$1,258.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
76102353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.37 |
| Max. Negotiated Rate |
$1,258.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.88
|
| Rate for Payer: Anthem Medicaid |
$92.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,258.00
|
| Rate for Payer: Cash Price |
$629.00
|
| Rate for Payer: Cash Price |
$629.00
|
| Rate for Payer: Cigna Commercial |
$267.96
|
| Rate for Payer: Healthspan PPO |
$211.18
|
| Rate for Payer: Humana Medicaid |
$92.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.22
|
| Rate for Payer: Molina Healthcare Passport |
$92.37
|
| Rate for Payer: Multiplan PHCS |
$754.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$880.60
|
| Rate for Payer: UHCCP Medicaid |
$98.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.29
|
|
|
CHEMODENERV 1 EXTREM 5/> MU(T
|
Facility
|
IP
|
$933.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
761T2353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$895.68 |
| Rate for Payer: Aetna Commercial |
$718.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$727.74
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cigna Commercial |
$774.39
|
| Rate for Payer: First Health Commercial |
$886.35
|
| Rate for Payer: Humana Commercial |
$793.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$688.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.04
|
| Rate for Payer: Ohio Health Group HMO |
$699.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.23
|
| Rate for Payer: PHCS Commercial |
$895.68
|
| Rate for Payer: United Healthcare All Payer |
$821.04
|
|
|
CHEMODENERV 1 EXTREM 5/> MU(T
|
Facility
|
OP
|
$933.00
|
|
|
Service Code
|
HCPCS 64644
|
| Hospital Charge Code |
761T2353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$895.68 |
| Rate for Payer: Aetna Commercial |
$718.41
|
| Rate for Payer: Anthem Medicaid |
$320.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$727.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cigna Commercial |
$774.39
|
| Rate for Payer: First Health Commercial |
$886.35
|
| Rate for Payer: Humana Commercial |
$793.05
|
| Rate for Payer: Humana KY Medicaid |
$320.86
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$324.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$688.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$327.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.04
|
| Rate for Payer: Ohio Health Group HMO |
$699.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.23
|
| Rate for Payer: PHCS Commercial |
$895.68
|
| Rate for Payer: United Healthcare All Payer |
$821.04
|
|
|
CHEMODENERV 1 EXTREMITY 1-4
|
Facility
|
IP
|
$1,208.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
76102351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$1,159.68 |
| Rate for Payer: Aetna Commercial |
$930.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$942.24
|
| Rate for Payer: Cash Price |
$604.00
|
| Rate for Payer: Cigna Commercial |
$1,002.64
|
| Rate for Payer: First Health Commercial |
$1,147.60
|
| Rate for Payer: Humana Commercial |
$1,026.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$990.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$891.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$362.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,063.04
|
| Rate for Payer: Ohio Health Group HMO |
$906.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.48
|
| Rate for Payer: PHCS Commercial |
$1,159.68
|
| Rate for Payer: United Healthcare All Payer |
$1,063.04
|
|
|
CHEMODENERV 1 EXTREMITY 1-4
|
Facility
|
OP
|
$1,208.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
76102351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$1,159.68 |
| Rate for Payer: Aetna Commercial |
$930.16
|
| Rate for Payer: Anthem Medicaid |
$415.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$942.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$604.00
|
| Rate for Payer: Cash Price |
$604.00
|
| Rate for Payer: Cigna Commercial |
$1,002.64
|
| Rate for Payer: First Health Commercial |
$1,147.60
|
| Rate for Payer: Humana Commercial |
$1,026.80
|
| Rate for Payer: Humana KY Medicaid |
$415.43
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$419.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$990.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$891.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$423.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,063.04
|
| Rate for Payer: Ohio Health Group HMO |
$906.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.48
|
| Rate for Payer: PHCS Commercial |
$1,159.68
|
| Rate for Payer: United Healthcare All Payer |
$1,063.04
|
|
|
CHEMODENERV 1 EXTREMITY 1-4
|
Professional
|
Both
|
$1,208.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
76102351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.53 |
| Max. Negotiated Rate |
$1,208.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$86.02
|
| Rate for Payer: Anthem Medicaid |
$84.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,208.00
|
| Rate for Payer: Cash Price |
$604.00
|
| Rate for Payer: Cash Price |
$604.00
|
| Rate for Payer: Cigna Commercial |
$234.95
|
| Rate for Payer: Healthspan PPO |
$185.37
|
| Rate for Payer: Humana Medicaid |
$84.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$137.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.22
|
| Rate for Payer: Molina Healthcare Passport |
$84.53
|
| Rate for Payer: Multiplan PHCS |
$724.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$845.60
|
| Rate for Payer: UHCCP Medicaid |
$90.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.38
|
|
|
CHEMODENERV 1 EXTREMITY 1-4(P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
761P2351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.53 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$86.02
|
| Rate for Payer: Anthem Medicaid |
$84.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$234.95
|
| Rate for Payer: Healthspan PPO |
$185.37
|
| Rate for Payer: Humana Medicaid |
$84.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$137.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.22
|
| Rate for Payer: Molina Healthcare Passport |
$84.53
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$90.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.38
|
|
|
CHEMODENERV 1 EXTREMITY 1-4(T
|
Facility
|
OP
|
$933.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
761T2351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$895.68 |
| Rate for Payer: Aetna Commercial |
$718.41
|
| Rate for Payer: Anthem Medicaid |
$320.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$727.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cigna Commercial |
$774.39
|
| Rate for Payer: First Health Commercial |
$886.35
|
| Rate for Payer: Humana Commercial |
$793.05
|
| Rate for Payer: Humana KY Medicaid |
$320.86
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$324.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$688.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$327.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.04
|
| Rate for Payer: Ohio Health Group HMO |
$699.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.23
|
| Rate for Payer: PHCS Commercial |
$895.68
|
| Rate for Payer: United Healthcare All Payer |
$821.04
|
|
|
CHEMODENERV 1 EXTREMITY 1-4(T
|
Facility
|
IP
|
$933.00
|
|
|
Service Code
|
HCPCS 64642
|
| Hospital Charge Code |
761T2351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.29 |
| Max. Negotiated Rate |
$895.68 |
| Rate for Payer: Aetna Commercial |
$718.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$727.74
|
| Rate for Payer: Cash Price |
$466.50
|
| Rate for Payer: Cigna Commercial |
$774.39
|
| Rate for Payer: First Health Commercial |
$886.35
|
| Rate for Payer: Humana Commercial |
$793.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$688.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.04
|
| Rate for Payer: Ohio Health Group HMO |
$699.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.23
|
| Rate for Payer: PHCS Commercial |
$895.68
|
| Rate for Payer: United Healthcare All Payer |
$821.04
|
|
|
CHEMODENERVATION ANAL MUSC
|
Professional
|
Both
|
$763.00
|
|
|
Service Code
|
HCPCS 46505
|
| Hospital Charge Code |
76102902
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.75 |
| Max. Negotiated Rate |
$763.00 |
| Rate for Payer: Aetna Commercial |
$310.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.38
|
| Rate for Payer: Anthem Medicaid |
$138.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$763.00
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$345.38
|
| Rate for Payer: Healthspan PPO |
$306.58
|
| Rate for Payer: Humana Medicaid |
$138.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$295.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$141.52
|
| Rate for Payer: Molina Healthcare Passport |
$138.75
|
| Rate for Payer: Multiplan PHCS |
$457.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$534.10
|
| Rate for Payer: UHCCP Medicaid |
$174.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.14
|
|
|
CHEMODENERVATION ANAL MUSC
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 46505
|
| Hospital Charge Code |
76102902
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
CHEMODENERVATION ANAL MUSC
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 46505
|
| Hospital Charge Code |
76102902
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$1,428.66 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,020.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,428.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,377.63
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,020.47
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,224.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
CHEMODENERVATION OF INTERNAL ANAL SPHINCTER
|
Facility
|
OP
|
$1,428.66
|
|
|
Service Code
|
CPT 46505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,020.47 |
| Max. Negotiated Rate |
$1,428.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,020.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,428.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,377.63
|
| Rate for Payer: Humana Medicare Advantage |
$1,020.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,224.56
|
|
|
CHEMODENERV ECCRINE GLANDS
|
Facility
|
IP
|
$679.00
|
|
|
Service Code
|
HCPCS 64650
|
| Hospital Charge Code |
76102357
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.27 |
| Max. Negotiated Rate |
$651.84 |
| Rate for Payer: Aetna Commercial |
$522.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$529.62
|
| Rate for Payer: Cash Price |
$339.50
|
| Rate for Payer: Cigna Commercial |
$563.57
|
| Rate for Payer: First Health Commercial |
$645.05
|
| Rate for Payer: Humana Commercial |
$577.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$556.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$203.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$597.52
|
| Rate for Payer: Ohio Health Group HMO |
$509.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.49
|
| Rate for Payer: PHCS Commercial |
$651.84
|
| Rate for Payer: United Healthcare All Payer |
$597.52
|
|
|
CHEMODENERV ECCRINE GLANDS
|
Professional
|
Both
|
$679.00
|
|
|
Service Code
|
HCPCS 64650
|
| Hospital Charge Code |
76102357
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$679.00 |
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$29.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$679.00
|
| Rate for Payer: Cash Price |
$339.50
|
| Rate for Payer: Cash Price |
$339.50
|
| Rate for Payer: Cigna Commercial |
$91.26
|
| Rate for Payer: Healthspan PPO |
$80.55
|
| Rate for Payer: Humana Medicaid |
$29.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$30.58
|
| Rate for Payer: Molina Healthcare Passport |
$29.98
|
| Rate for Payer: Multiplan PHCS |
$407.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$475.30
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$30.28
|
|
|
CHEMODENERV ECCRINE GLANDS
|
Facility
|
OP
|
$679.00
|
|
|
Service Code
|
HCPCS 64650
|
| Hospital Charge Code |
76102357
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.27 |
| Max. Negotiated Rate |
$651.84 |
| Rate for Payer: Aetna Commercial |
$522.83
|
| Rate for Payer: Anthem Medicaid |
$233.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$529.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$339.50
|
| Rate for Payer: Cash Price |
$339.50
|
| Rate for Payer: Cigna Commercial |
$563.57
|
| Rate for Payer: First Health Commercial |
$645.05
|
| Rate for Payer: Humana Commercial |
$577.15
|
| Rate for Payer: Humana KY Medicaid |
$233.51
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$235.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$556.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$238.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$597.52
|
| Rate for Payer: Ohio Health Group HMO |
$509.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.49
|
| Rate for Payer: PHCS Commercial |
$651.84
|
| Rate for Payer: United Healthcare All Payer |
$597.52
|
|
|
CHEMODENERV ECCRINE GLANDS
|
Professional
|
Both
|
$307.50
|
|
|
Service Code
|
HCPCS 64653
|
| Hospital Charge Code |
76102670
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.32 |
| Max. Negotiated Rate |
$307.50 |
| Rate for Payer: Aetna Commercial |
$80.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$35.32
|
| Rate for Payer: Anthem Medicaid |
$37.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$307.50
|
| Rate for Payer: Cash Price |
$153.75
|
| Rate for Payer: Cash Price |
$153.75
|
| Rate for Payer: Cigna Commercial |
$105.19
|
| Rate for Payer: Healthspan PPO |
$94.14
|
| Rate for Payer: Humana Medicaid |
$37.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$69.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.64
|
| Rate for Payer: Molina Healthcare Passport |
$37.88
|
| Rate for Payer: Multiplan PHCS |
$184.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$215.25
|
| Rate for Payer: UHCCP Medicaid |
$37.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.26
|
|
|
CHEMODENERV ECCRINE GLANDS(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 64650
|
| Hospital Charge Code |
761P2357
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$29.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$91.26
|
| Rate for Payer: Healthspan PPO |
$80.55
|
| Rate for Payer: Humana Medicaid |
$29.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$30.58
|
| Rate for Payer: Molina Healthcare Passport |
$29.98
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$30.28
|
|
|
CHEMODENERV ECCRINE GLANDS(T
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
HCPCS 64650
|
| Hospital Charge Code |
761T2357
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$483.84 |
| Rate for Payer: Aetna Commercial |
$388.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.12
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$418.32
|
| Rate for Payer: First Health Commercial |
$478.80
|
| Rate for Payer: Humana Commercial |
$428.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$413.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$443.52
|
| Rate for Payer: Ohio Health Group HMO |
$378.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.24
|
| Rate for Payer: PHCS Commercial |
$483.84
|
| Rate for Payer: United Healthcare All Payer |
$443.52
|
|
