|
DECADRON 1MG TABLET
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
25002539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
DECALCIFY TISSUE
|
Professional
|
Both
|
$79.00
|
|
|
Service Code
|
HCPCS 88311
|
| Hospital Charge Code |
30001511
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Aetna Commercial |
$28.13
|
| Rate for Payer: Ambetter Exchange |
$18.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.50
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cigna Commercial |
$11.65
|
| Rate for Payer: Healthspan PPO |
$26.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.75
|
| Rate for Payer: Multiplan PHCS |
$47.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.38
|
| Rate for Payer: UHCCP Medicaid |
$27.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$7.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.75
|
|
|
DECALCIFY TISSUE
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS 88311
|
| Hospital Charge Code |
30001511
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$23.70 |
| Max. Negotiated Rate |
$75.84 |
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem Medicaid |
$27.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.44
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana KY Medicaid |
$27.17
|
| Rate for Payer: Kentucky WC Medicaid |
$27.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
DECALCIFY TISSUE
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS 88311
|
| Hospital Charge Code |
30001511
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$23.70 |
| Max. Negotiated Rate |
$75.84 |
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.44
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.51
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
DECLOMYCIN(DEMECLOC 150MG/1TAB
|
Facility
|
OP
|
$23.33
|
|
|
Service Code
|
NDC 53746055401
|
| Hospital Charge Code |
25000524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna Commercial |
$17.96
|
| Rate for Payer: Anthem Medicaid |
$8.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.20
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: Cigna Commercial |
$19.36
|
| Rate for Payer: First Health Commercial |
$22.16
|
| Rate for Payer: Humana Commercial |
$19.83
|
| Rate for Payer: Humana KY Medicaid |
$8.02
|
| Rate for Payer: Kentucky WC Medicaid |
$8.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.53
|
| Rate for Payer: Ohio Health Group HMO |
$17.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.10
|
| Rate for Payer: PHCS Commercial |
$22.40
|
| Rate for Payer: United Healthcare All Payer |
$20.53
|
|
|
DECLOMYCIN(DEMECLOC 150MG/1TAB
|
Facility
|
IP
|
$23.33
|
|
|
Service Code
|
NDC 53746055401
|
| Hospital Charge Code |
25000524
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna Commercial |
$17.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.20
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: Cigna Commercial |
$19.36
|
| Rate for Payer: First Health Commercial |
$22.16
|
| Rate for Payer: Humana Commercial |
$19.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.53
|
| Rate for Payer: Ohio Health Group HMO |
$17.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.10
|
| Rate for Payer: PHCS Commercial |
$22.40
|
| Rate for Payer: United Healthcare All Payer |
$20.53
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
45000238
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$192.30 |
| Max. Negotiated Rate |
$615.36 |
| Rate for Payer: Aetna Commercial |
$493.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.98
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cigna Commercial |
$532.03
|
| Rate for Payer: First Health Commercial |
$608.95
|
| Rate for Payer: Humana Commercial |
$544.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$525.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$473.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$564.08
|
| Rate for Payer: Ohio Health Group HMO |
$480.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$557.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$442.29
|
| Rate for Payer: PHCS Commercial |
$615.36
|
| Rate for Payer: United Healthcare All Payer |
$564.08
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
45000238
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$220.44 |
| Max. Negotiated Rate |
$615.36 |
| Rate for Payer: Aetna Commercial |
$493.57
|
| Rate for Payer: Anthem Medicaid |
$220.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$306.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$429.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$413.73
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cigna Commercial |
$532.03
|
| Rate for Payer: First Health Commercial |
$608.95
|
| Rate for Payer: Humana Commercial |
$544.85
|
| Rate for Payer: Humana KY Medicaid |
$220.44
|
| Rate for Payer: Humana Medicare Advantage |
$306.47
|
| Rate for Payer: Kentucky WC Medicaid |
$222.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$525.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$473.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$564.08
|
| Rate for Payer: Ohio Health Group HMO |
$480.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$557.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$442.29
|
| Rate for Payer: PHCS Commercial |
$615.36
|
| Rate for Payer: United Healthcare All Payer |
$564.08
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
76102777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.03 |
| Max. Negotiated Rate |
$577.92 |
| Rate for Payer: Aetna Commercial |
$463.54
|
| Rate for Payer: Anthem Medicaid |
$207.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$306.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$469.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$429.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$413.73
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cigna Commercial |
$499.66
|
| Rate for Payer: First Health Commercial |
$571.90
|
| Rate for Payer: Humana Commercial |
$511.70
|
| Rate for Payer: Humana KY Medicaid |
$207.03
|
| Rate for Payer: Humana Medicare Advantage |
$306.47
|
| Rate for Payer: Kentucky WC Medicaid |
$209.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$493.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$444.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$211.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.76
|
| Rate for Payer: Ohio Health Group HMO |
$451.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$481.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$415.38
|
| Rate for Payer: PHCS Commercial |
$577.92
|
| Rate for Payer: United Healthcare All Payer |
$529.76
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
IP
|
$641.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
76101493
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.30 |
| Max. Negotiated Rate |
$615.36 |
| Rate for Payer: Aetna Commercial |
$493.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.98
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cigna Commercial |
$532.03
|
| Rate for Payer: First Health Commercial |
$608.95
|
| Rate for Payer: Humana Commercial |
$544.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$525.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$473.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$564.08
|
| Rate for Payer: Ohio Health Group HMO |
$480.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$557.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$442.29
|
| Rate for Payer: PHCS Commercial |
$615.36
|
| Rate for Payer: United Healthcare All Payer |
$564.08
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
76102777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$180.60 |
| Max. Negotiated Rate |
$577.92 |
| Rate for Payer: Aetna Commercial |
$463.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$469.56
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cigna Commercial |
$499.66
|
| Rate for Payer: First Health Commercial |
$571.90
|
| Rate for Payer: Humana Commercial |
$511.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$493.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$444.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.76
|
| Rate for Payer: Ohio Health Group HMO |
$451.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$481.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$415.38
|
| Rate for Payer: PHCS Commercial |
$577.92
|
| Rate for Payer: United Healthcare All Payer |
$529.76
|
|
|
DECLOT IMPLANTED VASC ACC DEV
|
Facility
|
OP
|
$641.00
|
|
|
Service Code
|
HCPCS 36593
|
| Hospital Charge Code |
76101493
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.44 |
| Max. Negotiated Rate |
$615.36 |
| Rate for Payer: Aetna Commercial |
$493.57
|
| Rate for Payer: Anthem Medicaid |
$220.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$306.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$429.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$413.73
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cash Price |
$320.50
|
| Rate for Payer: Cigna Commercial |
$532.03
|
| Rate for Payer: First Health Commercial |
$608.95
|
| Rate for Payer: Humana Commercial |
$544.85
|
| Rate for Payer: Humana KY Medicaid |
$220.44
|
| Rate for Payer: Humana Medicare Advantage |
$306.47
|
| Rate for Payer: Kentucky WC Medicaid |
$222.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$525.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$473.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$564.08
|
| Rate for Payer: Ohio Health Group HMO |
$480.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$557.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$442.29
|
| Rate for Payer: PHCS Commercial |
$615.36
|
| Rate for Payer: United Healthcare All Payer |
$564.08
|
|
|
DECOMP FASCIOTOMY,LUMBAR PARAS
|
Facility
|
IP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$310.50 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$828.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$900.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$714.15
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
DECOMP FASCIOTOMY,LUMBAR PARAS
|
Facility
|
OP
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$993.60 |
| Rate for Payer: Aetna Commercial |
$796.95
|
| Rate for Payer: Anthem Medicaid |
$355.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$807.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cigna Commercial |
$859.05
|
| Rate for Payer: First Health Commercial |
$983.25
|
| Rate for Payer: Humana Commercial |
$879.75
|
| Rate for Payer: Humana KY Medicaid |
$355.94
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$359.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$363.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$910.80
|
| Rate for Payer: Ohio Health Group HMO |
$776.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$828.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$900.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$714.15
|
| Rate for Payer: PHCS Commercial |
$993.60
|
| Rate for Payer: United Healthcare All Payer |
$910.80
|
|
|
DECOMP FASCIOTOMY,LUMBAR PARAS
|
Professional
|
Both
|
$1,035.00
|
|
|
Service Code
|
HCPCS 20999
|
| Hospital Charge Code |
76102804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$724.50 |
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Cash Price |
$517.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$621.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$724.50
|
| Rate for Payer: UHCCP Medicaid |
$362.25
|
|
|
DECOMP. LOWER LET
|
Facility
|
OP
|
$5,593.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
76100883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,923.43 |
| Max. Negotiated Rate |
$5,369.28 |
| Rate for Payer: Aetna Commercial |
$4,306.61
|
| Rate for Payer: Anthem Medicaid |
$1,923.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,362.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cigna Commercial |
$4,642.19
|
| Rate for Payer: First Health Commercial |
$5,313.35
|
| Rate for Payer: Humana Commercial |
$4,754.05
|
| Rate for Payer: Humana KY Medicaid |
$1,923.43
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,943.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,586.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,127.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,962.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,921.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,194.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,474.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,865.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,859.17
|
| Rate for Payer: PHCS Commercial |
$5,369.28
|
| Rate for Payer: United Healthcare All Payer |
$4,921.84
|
|
|
DECOMP. LOWER LET
|
Facility
|
IP
|
$5,593.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
76100883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,677.90 |
| Max. Negotiated Rate |
$5,369.28 |
| Rate for Payer: Aetna Commercial |
$4,306.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,362.54
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cigna Commercial |
$4,642.19
|
| Rate for Payer: First Health Commercial |
$5,313.35
|
| Rate for Payer: Humana Commercial |
$4,754.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,586.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,127.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,677.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,921.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,194.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,474.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,865.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,859.17
|
| Rate for Payer: PHCS Commercial |
$5,369.28
|
| Rate for Payer: United Healthcare All Payer |
$4,921.84
|
|
|
DECOMP. LOWER LET
|
Professional
|
Both
|
$5,593.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
76100883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$3,355.80 |
| Rate for Payer: Aetna Commercial |
$623.57
|
| Rate for Payer: Ambetter Exchange |
$381.46
|
| Rate for Payer: Anthem Medicaid |
$253.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$381.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$381.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$457.75
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cigna Commercial |
$683.27
|
| Rate for Payer: Healthspan PPO |
$564.82
|
| Rate for Payer: Humana Medicaid |
$253.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$528.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$381.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$381.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$258.86
|
| Rate for Payer: Molina Healthcare Passport |
$253.78
|
| Rate for Payer: Multiplan PHCS |
$3,355.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$495.90
|
| Rate for Payer: UHCCP Medicaid |
$1,957.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$256.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$381.46
|
|
|
DECOMP. LOWER LET(P
|
Professional
|
Both
|
$775.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
761P0883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$683.27 |
| Rate for Payer: Aetna Commercial |
$623.57
|
| Rate for Payer: Ambetter Exchange |
$381.46
|
| Rate for Payer: Anthem Medicaid |
$253.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$381.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$381.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$457.75
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cigna Commercial |
$683.27
|
| Rate for Payer: Healthspan PPO |
$564.82
|
| Rate for Payer: Humana Medicaid |
$253.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$528.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$381.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$381.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$258.86
|
| Rate for Payer: Molina Healthcare Passport |
$253.78
|
| Rate for Payer: Multiplan PHCS |
$465.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$495.90
|
| Rate for Payer: UHCCP Medicaid |
$271.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$256.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$381.46
|
|
|
DECOMP. LOWER LET(T
|
Facility
|
OP
|
$4,818.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
761T0883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,656.91 |
| Max. Negotiated Rate |
$4,625.28 |
| Rate for Payer: Aetna Commercial |
$3,709.86
|
| Rate for Payer: Anthem Medicaid |
$1,656.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,758.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$2,409.00
|
| Rate for Payer: Cash Price |
$2,409.00
|
| Rate for Payer: Cigna Commercial |
$3,998.94
|
| Rate for Payer: First Health Commercial |
$4,577.10
|
| Rate for Payer: Humana Commercial |
$4,095.30
|
| Rate for Payer: Humana KY Medicaid |
$1,656.91
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,673.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,950.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,555.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,690.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,239.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,613.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,854.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,191.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,324.42
|
| Rate for Payer: PHCS Commercial |
$4,625.28
|
| Rate for Payer: United Healthcare All Payer |
$4,239.84
|
|
|
DECOMP. LOWER LET(T
|
Facility
|
IP
|
$4,818.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
761T0883
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,445.40 |
| Max. Negotiated Rate |
$4,625.28 |
| Rate for Payer: Aetna Commercial |
$3,709.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,758.04
|
| Rate for Payer: Cash Price |
$2,409.00
|
| Rate for Payer: Cigna Commercial |
$3,998.94
|
| Rate for Payer: First Health Commercial |
$4,577.10
|
| Rate for Payer: Humana Commercial |
$4,095.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,950.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,555.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,445.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,239.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,613.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,854.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,191.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,324.42
|
| Rate for Payer: PHCS Commercial |
$4,625.28
|
| Rate for Payer: United Healthcare All Payer |
$4,239.84
|
|
|
DECOMPRESS FASCIOTOMY - FOREAR
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 25023
|
| Hospital Charge Code |
76100566
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
DECOMPRESS FASCIOTOMY - FOREAR
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 25023
|
| Hospital Charge Code |
761P0566
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.01 |
| Max. Negotiated Rate |
$1,830.59 |
| Rate for Payer: Aetna Commercial |
$1,587.93
|
| Rate for Payer: Ambetter Exchange |
$1,214.60
|
| Rate for Payer: Anthem Medicaid |
$515.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,214.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,214.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,457.52
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,830.59
|
| Rate for Payer: Healthspan PPO |
$1,438.33
|
| Rate for Payer: Humana Medicaid |
$515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,362.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,214.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,214.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$525.31
|
| Rate for Payer: Molina Healthcare Passport |
$515.01
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,578.98
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$520.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,214.60
|
|
|
DECOMPRESS FASCIOTOMY - FOREAR
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 25023
|
| Hospital Charge Code |
76100566
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.01 |
| Max. Negotiated Rate |
$1,830.59 |
| Rate for Payer: Aetna Commercial |
$1,587.93
|
| Rate for Payer: Ambetter Exchange |
$1,214.60
|
| Rate for Payer: Anthem Medicaid |
$515.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,214.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,214.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,457.52
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,830.59
|
| Rate for Payer: Healthspan PPO |
$1,438.33
|
| Rate for Payer: Humana Medicaid |
$515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,362.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,214.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,214.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$525.31
|
| Rate for Payer: Molina Healthcare Passport |
$515.01
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,578.98
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$520.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,214.60
|
|
|
DECOMPRESS FASCIOTOMY - FOREAR
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 25023
|
| Hospital Charge Code |
76100566
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$619.02 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
