|
DOXY+NYST+HC Mouthwash 120mL
|
Facility
|
IP
|
$53.96
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
25004124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.19 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$41.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.09
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$44.79
|
| Rate for Payer: First Health Commercial |
$51.26
|
| Rate for Payer: Humana Commercial |
$45.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.48
|
| Rate for Payer: Ohio Health Group HMO |
$40.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.23
|
| Rate for Payer: PHCS Commercial |
$51.80
|
| Rate for Payer: United Healthcare All Payer |
$47.48
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
45000206
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.40
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
45000206
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.40
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$171.95 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$167.19
|
| Rate for Payer: Ambetter Exchange |
$114.71
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.46
|
| Rate for Payer: Anthem Medicaid |
$58.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.65
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$279.24
|
| Rate for Payer: Healthspan PPO |
$252.02
|
| Rate for Payer: Humana Medicaid |
$58.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.21
|
| Rate for Payer: Molina Healthcare Passport |
$58.05
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.12
|
| Rate for Payer: UHCCP Medicaid |
$68.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.71
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
761P1118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.05 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$167.19
|
| Rate for Payer: Ambetter Exchange |
$114.71
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.46
|
| Rate for Payer: Anthem Medicaid |
$58.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.65
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$279.24
|
| Rate for Payer: Healthspan PPO |
$252.02
|
| Rate for Payer: Humana Medicaid |
$58.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.21
|
| Rate for Payer: Molina Healthcare Passport |
$58.05
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.12
|
| Rate for Payer: UHCCP Medicaid |
$68.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.71
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLA(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
761P1665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.07 |
| Max. Negotiated Rate |
$255.68 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Ambetter Exchange |
$146.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.56
|
| Rate for Payer: Anthem Medicaid |
$53.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$146.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$146.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$175.51
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$157.30
|
| Rate for Payer: Healthspan PPO |
$255.68
|
| Rate for Payer: Humana Medicaid |
$53.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$146.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.13
|
| Rate for Payer: Molina Healthcare Passport |
$53.07
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$190.14
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$146.26
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
IP
|
$857.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
76101665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$257.10 |
| Max. Negotiated Rate |
$822.72 |
| Rate for Payer: Aetna Commercial |
$659.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$668.46
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cigna Commercial |
$711.31
|
| Rate for Payer: First Health Commercial |
$814.15
|
| Rate for Payer: Humana Commercial |
$728.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$702.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$632.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$754.16
|
| Rate for Payer: Ohio Health Group HMO |
$642.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$745.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.33
|
| Rate for Payer: PHCS Commercial |
$822.72
|
| Rate for Payer: United Healthcare All Payer |
$754.16
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
45000255
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$486.72 |
| Rate for Payer: Aetna Commercial |
$390.39
|
| Rate for Payer: Anthem Medicaid |
$174.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$395.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cigna Commercial |
$420.81
|
| Rate for Payer: First Health Commercial |
$481.65
|
| Rate for Payer: Humana Commercial |
$430.95
|
| Rate for Payer: Humana KY Medicaid |
$174.36
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$176.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$415.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$446.16
|
| Rate for Payer: Ohio Health Group HMO |
$380.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.83
|
| Rate for Payer: PHCS Commercial |
$486.72
|
| Rate for Payer: United Healthcare All Payer |
$446.16
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
OP
|
$857.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
76101665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$822.72 |
| Rate for Payer: Aetna Commercial |
$659.89
|
| Rate for Payer: Anthem Medicaid |
$294.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$668.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cigna Commercial |
$711.31
|
| Rate for Payer: First Health Commercial |
$814.15
|
| Rate for Payer: Humana Commercial |
$728.45
|
| Rate for Payer: Humana KY Medicaid |
$294.72
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$297.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$702.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$632.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$300.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$754.16
|
| Rate for Payer: Ohio Health Group HMO |
$642.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$745.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.33
|
| Rate for Payer: PHCS Commercial |
$822.72
|
| Rate for Payer: United Healthcare All Payer |
$754.16
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Professional
|
Both
|
$857.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
76101665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.07 |
| Max. Negotiated Rate |
$514.20 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Ambetter Exchange |
$146.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.56
|
| Rate for Payer: Anthem Medicaid |
$53.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$146.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$146.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$175.51
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cigna Commercial |
$157.30
|
| Rate for Payer: Healthspan PPO |
$255.68
|
| Rate for Payer: Humana Medicaid |
$53.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$146.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.13
|
| Rate for Payer: Molina Healthcare Passport |
$53.07
|
| Rate for Payer: Multiplan PHCS |
$514.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$190.14
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$146.26
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
IP
|
$507.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
45000255
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.10 |
| Max. Negotiated Rate |
$486.72 |
| Rate for Payer: Aetna Commercial |
$390.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$395.46
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cigna Commercial |
$420.81
|
| Rate for Payer: First Health Commercial |
$481.65
|
| Rate for Payer: Humana Commercial |
$430.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$415.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$446.16
|
| Rate for Payer: Ohio Health Group HMO |
$380.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.83
|
| Rate for Payer: PHCS Commercial |
$486.72
|
| Rate for Payer: United Healthcare All Payer |
$446.16
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLA(T
|
Facility
|
OP
|
$507.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
761T1665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$486.72 |
| Rate for Payer: Aetna Commercial |
$390.39
|
| Rate for Payer: Anthem Medicaid |
$174.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$395.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cigna Commercial |
$420.81
|
| Rate for Payer: First Health Commercial |
$481.65
|
| Rate for Payer: Humana Commercial |
$430.95
|
| Rate for Payer: Humana KY Medicaid |
$174.36
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$176.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$415.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$446.16
|
| Rate for Payer: Ohio Health Group HMO |
$380.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.83
|
| Rate for Payer: PHCS Commercial |
$486.72
|
| Rate for Payer: United Healthcare All Payer |
$446.16
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLA(T
|
Facility
|
IP
|
$507.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
761T1665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.10 |
| Max. Negotiated Rate |
$486.72 |
| Rate for Payer: Aetna Commercial |
$390.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$395.46
|
| Rate for Payer: Cash Price |
$253.50
|
| Rate for Payer: Cigna Commercial |
$420.81
|
| Rate for Payer: First Health Commercial |
$481.65
|
| Rate for Payer: Humana Commercial |
$430.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$415.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$374.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$446.16
|
| Rate for Payer: Ohio Health Group HMO |
$380.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.83
|
| Rate for Payer: PHCS Commercial |
$486.72
|
| Rate for Payer: United Healthcare All Payer |
$446.16
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
761P1629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.41 |
| Max. Negotiated Rate |
$252.31 |
| Rate for Payer: Aetna Commercial |
$177.50
|
| Rate for Payer: Ambetter Exchange |
$111.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$85.75
|
| Rate for Payer: Anthem Medicaid |
$54.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.93
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$252.31
|
| Rate for Payer: Healthspan PPO |
$228.23
|
| Rate for Payer: Humana Medicaid |
$54.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$111.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$55.50
|
| Rate for Payer: Molina Healthcare Passport |
$54.41
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$145.09
|
| Rate for Payer: UHCCP Medicaid |
$90.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.61
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
45000247
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$311.23 |
| Max. Negotiated Rate |
$910.14 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem Medicaid |
$311.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Humana KY Medicaid |
$311.23
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$314.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$317.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.45
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
OP
|
$1,155.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
76101629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,108.80 |
| Rate for Payer: Aetna Commercial |
$889.35
|
| Rate for Payer: Anthem Medicaid |
$397.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$900.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cigna Commercial |
$958.65
|
| Rate for Payer: First Health Commercial |
$1,097.25
|
| Rate for Payer: Humana Commercial |
$981.75
|
| Rate for Payer: Humana KY Medicaid |
$397.20
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$401.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$947.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$852.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$405.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,016.40
|
| Rate for Payer: Ohio Health Group HMO |
$866.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$924.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$796.95
|
| Rate for Payer: PHCS Commercial |
$1,108.80
|
| Rate for Payer: United Healthcare All Payer |
$1,016.40
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
761T1629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$271.50 |
| Max. Negotiated Rate |
$868.80 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.45
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Professional
|
Both
|
$1,155.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
76101629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.41 |
| Max. Negotiated Rate |
$693.00 |
| Rate for Payer: Aetna Commercial |
$177.50
|
| Rate for Payer: Ambetter Exchange |
$111.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$85.75
|
| Rate for Payer: Anthem Medicaid |
$54.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.93
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cigna Commercial |
$252.31
|
| Rate for Payer: Healthspan PPO |
$228.23
|
| Rate for Payer: Humana Medicaid |
$54.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$111.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$55.50
|
| Rate for Payer: Molina Healthcare Passport |
$54.41
|
| Rate for Payer: Multiplan PHCS |
$693.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$145.09
|
| Rate for Payer: UHCCP Medicaid |
$90.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.61
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
761T1629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$311.23 |
| Max. Negotiated Rate |
$910.14 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem Medicaid |
$311.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Humana KY Medicaid |
$311.23
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$314.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$317.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.45
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
45000247
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$271.50 |
| Max. Negotiated Rate |
$868.80 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$787.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.45
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
DRAIN ABSCESCYSTHEMAMOUTHSMPLE
|
Facility
|
IP
|
$1,155.00
|
|
|
Service Code
|
HCPCS 40800
|
| Hospital Charge Code |
76101629
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$346.50 |
| Max. Negotiated Rate |
$1,108.80 |
| Rate for Payer: Aetna Commercial |
$889.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$900.90
|
| Rate for Payer: Cash Price |
$577.50
|
| Rate for Payer: Cigna Commercial |
$958.65
|
| Rate for Payer: First Health Commercial |
$1,097.25
|
| Rate for Payer: Humana Commercial |
$981.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$947.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$852.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,016.40
|
| Rate for Payer: Ohio Health Group HMO |
$866.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$924.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$796.95
|
| Rate for Payer: PHCS Commercial |
$1,108.80
|
| Rate for Payer: United Healthcare All Payer |
$1,016.40
|
|
|
DRAIN ABSCES PAROTID SIMPLE
|
Facility
|
IP
|
$3,246.00
|
|
|
Service Code
|
HCPCS 42300
|
| Hospital Charge Code |
45000260
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$973.80 |
| Max. Negotiated Rate |
$3,116.16 |
| Rate for Payer: Aetna Commercial |
$2,499.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,531.88
|
| Rate for Payer: Cash Price |
$1,623.00
|
| Rate for Payer: Cigna Commercial |
$2,694.18
|
| Rate for Payer: First Health Commercial |
$3,083.70
|
| Rate for Payer: Humana Commercial |
$2,759.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,661.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,395.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$973.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,856.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,434.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,596.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,824.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,239.74
|
| Rate for Payer: PHCS Commercial |
$3,116.16
|
| Rate for Payer: United Healthcare All Payer |
$2,856.48
|
|
|
DRAIN ABSCES PAROTID SIMPLE
|
Facility
|
OP
|
$3,596.00
|
|
|
Service Code
|
HCPCS 42300
|
| Hospital Charge Code |
76101678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,236.66 |
| Max. Negotiated Rate |
$3,452.16 |
| Rate for Payer: Aetna Commercial |
$2,768.92
|
| Rate for Payer: Anthem Medicaid |
$1,236.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,804.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$1,798.00
|
| Rate for Payer: Cash Price |
$1,798.00
|
| Rate for Payer: Cigna Commercial |
$2,984.68
|
| Rate for Payer: First Health Commercial |
$3,416.20
|
| Rate for Payer: Humana Commercial |
$3,056.60
|
| Rate for Payer: Humana KY Medicaid |
$1,236.66
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,249.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,948.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,653.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,261.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,164.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,697.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,876.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,128.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,481.24
|
| Rate for Payer: PHCS Commercial |
$3,452.16
|
| Rate for Payer: United Healthcare All Payer |
$3,164.48
|
|
