|
DRAIN RETROPERITONEAL ABSCESS
|
Facility
|
IP
|
$1,491.00
|
|
|
Service Code
|
HCPCS 49060
|
| Hospital Charge Code |
76101978
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$193.83 |
| Max. Negotiated Rate |
$1,431.36 |
| Rate for Payer: Aetna Commercial |
$1,148.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,162.98
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$1,237.53
|
| Rate for Payer: First Health Commercial |
$1,416.45
|
| Rate for Payer: Humana Commercial |
$1,267.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,222.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,100.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$447.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,312.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,118.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$298.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$193.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$462.21
|
| Rate for Payer: PHCS Commercial |
$1,431.36
|
| Rate for Payer: United Healthcare All Payer |
$1,312.08
|
|
|
DRAIN RETROPERITONEAL ABSCESS
|
Professional
|
Both
|
$1,491.00
|
|
|
Service Code
|
HCPCS 49060
|
| Hospital Charge Code |
76101978
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$482.71 |
| Max. Negotiated Rate |
$1,591.53 |
| Rate for Payer: Aetna Commercial |
$1,591.53
|
| Rate for Payer: Anthem Medicaid |
$482.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,491.00
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$1,483.31
|
| Rate for Payer: Healthspan PPO |
$1,342.17
|
| Rate for Payer: Humana Medicaid |
$482.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,412.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$492.36
|
| Rate for Payer: Molina Healthcare Passport |
$482.71
|
| Rate for Payer: Multiplan PHCS |
$894.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,043.70
|
| Rate for Payer: UHCCP Medicaid |
$521.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$487.54
|
|
|
DRAIN SHOULDER BONE LESION
|
Professional
|
Both
|
$885.00
|
|
|
Service Code
|
HCPCS 23035
|
| Hospital Charge Code |
76102689
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$309.75 |
| Max. Negotiated Rate |
$1,132.95 |
| Rate for Payer: Aetna Commercial |
$1,001.68
|
| Rate for Payer: Anthem Medicaid |
$420.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$885.00
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$1,132.95
|
| Rate for Payer: Healthspan PPO |
$907.31
|
| Rate for Payer: Humana Medicaid |
$420.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$844.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$429.40
|
| Rate for Payer: Molina Healthcare Passport |
$420.98
|
| Rate for Payer: Multiplan PHCS |
$531.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$619.50
|
| Rate for Payer: UHCCP Medicaid |
$309.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$425.19
|
|
|
DRAIN SHOULDER BURSA
|
Facility
|
OP
|
$3,971.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
76100433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$516.23 |
| Max. Negotiated Rate |
$3,812.16 |
| Rate for Payer: Aetna Commercial |
$3,057.67
|
| Rate for Payer: Anthem Medicaid |
$1,365.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,097.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$1,985.50
|
| Rate for Payer: Cash Price |
$1,985.50
|
| Rate for Payer: Cigna Commercial |
$3,295.93
|
| Rate for Payer: First Health Commercial |
$3,772.45
|
| Rate for Payer: Humana Commercial |
$3,375.35
|
| Rate for Payer: Humana KY Medicaid |
$1,365.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,379.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,256.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,930.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,393.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,494.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,978.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$794.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,231.01
|
| Rate for Payer: PHCS Commercial |
$3,812.16
|
| Rate for Payer: United Healthcare All Payer |
$3,494.48
|
|
|
DRAIN SHOULDER BURSA
|
Facility
|
IP
|
$3,971.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
76100433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$516.23 |
| Max. Negotiated Rate |
$3,812.16 |
| Rate for Payer: Aetna Commercial |
$3,057.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,097.38
|
| Rate for Payer: Cash Price |
$1,985.50
|
| Rate for Payer: Cigna Commercial |
$3,295.93
|
| Rate for Payer: First Health Commercial |
$3,772.45
|
| Rate for Payer: Humana Commercial |
$3,375.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,256.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,930.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,191.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,494.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,978.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$794.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,231.01
|
| Rate for Payer: PHCS Commercial |
$3,812.16
|
| Rate for Payer: United Healthcare All Payer |
$3,494.48
|
|
|
DRAIN SHOULDER BURSA
|
Professional
|
Both
|
$3,971.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
76100433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.85 |
| Max. Negotiated Rate |
$3,971.00 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$112.65
|
| Rate for Payer: Anthem Medicaid |
$86.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,971.00
|
| Rate for Payer: Cash Price |
$1,985.50
|
| Rate for Payer: Cash Price |
$1,985.50
|
| Rate for Payer: Cigna Commercial |
$357.06
|
| Rate for Payer: Healthspan PPO |
$482.79
|
| Rate for Payer: Humana Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.59
|
| Rate for Payer: Molina Healthcare Passport |
$86.85
|
| Rate for Payer: Multiplan PHCS |
$2,382.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,779.70
|
| Rate for Payer: UHCCP Medicaid |
$118.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.72
|
|
|
DRAIN SHOULDER BURSA(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
761P0433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.85 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$112.65
|
| Rate for Payer: Anthem Medicaid |
$86.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$357.06
|
| Rate for Payer: Healthspan PPO |
$482.79
|
| Rate for Payer: Humana Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.59
|
| Rate for Payer: Molina Healthcare Passport |
$86.85
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$118.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.72
|
|
|
DRAIN SHOULDER BURSA(T
|
Facility
|
OP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
761T0433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$431.73 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem Medicaid |
$1,142.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Humana KY Medicaid |
$1,142.09
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,165.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$431.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,029.51
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
|
DRAIN SHOULDER BURSA(T
|
Facility
|
IP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 23031
|
| Hospital Charge Code |
761T0433
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$431.73 |
| Max. Negotiated Rate |
$3,188.16 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$431.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,029.51
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
|
DRAMAMINE 50MG TABLET
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 31248000197
|
| Hospital Charge Code |
25000581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.27
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna Commercial |
$0.29
|
| Rate for Payer: First Health Commercial |
$0.33
|
| Rate for Payer: Humana Commercial |
$0.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.31
|
| Rate for Payer: Ohio Health Group HMO |
$0.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.11
|
| Rate for Payer: PHCS Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Payer |
$0.31
|
|
|
DRAMAMINE 50MG TABLET
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 10135017736
|
| Hospital Charge Code |
25000581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
DRAMAMINE 50MG TABLET
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 10135017736
|
| Hospital Charge Code |
25000581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
DRAMAMINE 50MG TABLET
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 31248000197
|
| Hospital Charge Code |
25000581
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.27
|
| Rate for Payer: Anthem Medicaid |
$0.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.27
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna Commercial |
$0.29
|
| Rate for Payer: First Health Commercial |
$0.33
|
| Rate for Payer: Humana Commercial |
$0.30
|
| Rate for Payer: Humana KY Medicaid |
$0.12
|
| Rate for Payer: Kentucky WC Medicaid |
$0.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.31
|
| Rate for Payer: Ohio Health Group HMO |
$0.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.11
|
| Rate for Payer: PHCS Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Payer |
$0.31
|
|
|
DREAMWIRE ST .035*260
|
Facility
|
OP
|
$1,975.13
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.77 |
| Max. Negotiated Rate |
$1,896.12 |
| Rate for Payer: Aetna Commercial |
$1,520.85
|
| Rate for Payer: Anthem Medicaid |
$679.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,540.60
|
| Rate for Payer: Cash Price |
$987.57
|
| Rate for Payer: Cigna Commercial |
$1,639.36
|
| Rate for Payer: First Health Commercial |
$1,876.37
|
| Rate for Payer: Humana Commercial |
$1,678.86
|
| Rate for Payer: Humana KY Medicaid |
$679.25
|
| Rate for Payer: Kentucky WC Medicaid |
$686.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,619.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,457.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$592.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$692.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,738.11
|
| Rate for Payer: Ohio Health Group HMO |
$1,481.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.29
|
| Rate for Payer: PHCS Commercial |
$1,896.12
|
| Rate for Payer: United Healthcare All Payer |
$1,738.11
|
|
|
DREAMWIRE ST .035*260
|
Facility
|
IP
|
$1,975.13
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.77 |
| Max. Negotiated Rate |
$1,896.12 |
| Rate for Payer: Aetna Commercial |
$1,520.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,540.60
|
| Rate for Payer: Cash Price |
$987.57
|
| Rate for Payer: Cigna Commercial |
$1,639.36
|
| Rate for Payer: First Health Commercial |
$1,876.37
|
| Rate for Payer: Humana Commercial |
$1,678.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,619.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,457.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$592.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,738.11
|
| Rate for Payer: Ohio Health Group HMO |
$1,481.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.29
|
| Rate for Payer: PHCS Commercial |
$1,896.12
|
| Rate for Payer: United Healthcare All Payer |
$1,738.11
|
|
|
DREAMWIRE ST SS .035*450
|
Facility
|
IP
|
$1,975.13
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.77 |
| Max. Negotiated Rate |
$1,896.12 |
| Rate for Payer: Aetna Commercial |
$1,520.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,540.60
|
| Rate for Payer: Cash Price |
$987.57
|
| Rate for Payer: Cigna Commercial |
$1,639.36
|
| Rate for Payer: First Health Commercial |
$1,876.37
|
| Rate for Payer: Humana Commercial |
$1,678.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,619.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,457.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$592.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,738.11
|
| Rate for Payer: Ohio Health Group HMO |
$1,481.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.29
|
| Rate for Payer: PHCS Commercial |
$1,896.12
|
| Rate for Payer: United Healthcare All Payer |
$1,738.11
|
|
|
DREAMWIRE ST SS .035*450
|
Facility
|
OP
|
$1,975.13
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.77 |
| Max. Negotiated Rate |
$1,896.12 |
| Rate for Payer: Aetna Commercial |
$1,520.85
|
| Rate for Payer: Anthem Medicaid |
$679.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,540.60
|
| Rate for Payer: Cash Price |
$987.57
|
| Rate for Payer: Cigna Commercial |
$1,639.36
|
| Rate for Payer: First Health Commercial |
$1,876.37
|
| Rate for Payer: Humana Commercial |
$1,678.86
|
| Rate for Payer: Humana KY Medicaid |
$679.25
|
| Rate for Payer: Kentucky WC Medicaid |
$686.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,619.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,457.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$592.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$692.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,738.11
|
| Rate for Payer: Ohio Health Group HMO |
$1,481.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$395.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.29
|
| Rate for Payer: PHCS Commercial |
$1,896.12
|
| Rate for Payer: United Healthcare All Payer |
$1,738.11
|
|
|
DRES DEBR BURN W/O ANES SM
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$415.00 |
| Rate for Payer: Aetna Commercial |
$81.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.83
|
| Rate for Payer: Anthem Medicaid |
$28.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$415.00
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$115.98
|
| Rate for Payer: Healthspan PPO |
$90.27
|
| Rate for Payer: Humana Medicaid |
$28.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$70.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.34
|
| Rate for Payer: Molina Healthcare Passport |
$28.76
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$290.50
|
| Rate for Payer: UHCCP Medicaid |
$34.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.05
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
45000078
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
45000078
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem Medicaid |
$101.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Humana KY Medicaid |
$101.45
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem Medicaid |
$142.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Humana KY Medicaid |
$142.72
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$144.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
DRES DEBR BURN W/O ANES SM(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761P0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$81.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.83
|
| Rate for Payer: Anthem Medicaid |
$28.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$115.98
|
| Rate for Payer: Healthspan PPO |
$90.27
|
| Rate for Payer: Humana Medicaid |
$28.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$70.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.34
|
| Rate for Payer: Molina Healthcare Passport |
$28.76
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$34.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.05
|
|
|
DRES DEBR BURN W/O ANES SM(T
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761T0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
DRES DEBR BURN W/O ANES SM(T
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761T0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem Medicaid |
$101.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Humana KY Medicaid |
$101.45
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
