|
EXPANDER DERMA SMTH FUL 13*11
|
Facility
|
OP
|
$7,726.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.03 |
| Max. Negotiated Rate |
$7,417.68 |
| Rate for Payer: Aetna Commercial |
$5,949.60
|
| Rate for Payer: Anthem Medicaid |
$2,657.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,026.86
|
| Rate for Payer: Cash Price |
$3,863.38
|
| Rate for Payer: Cigna Commercial |
$6,413.20
|
| Rate for Payer: First Health Commercial |
$7,340.41
|
| Rate for Payer: Humana Commercial |
$6,567.74
|
| Rate for Payer: Humana KY Medicaid |
$2,657.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,684.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,335.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,799.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,181.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,722.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,331.46
|
| Rate for Payer: PHCS Commercial |
$7,417.68
|
| Rate for Payer: United Healthcare All Payer |
$6,799.54
|
|
|
EXPANDER SMOOTH 15*11.5 500CC
|
Facility
|
IP
|
$7,726.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.03 |
| Max. Negotiated Rate |
$7,417.68 |
| Rate for Payer: Aetna Commercial |
$5,949.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,026.86
|
| Rate for Payer: Cash Price |
$3,863.38
|
| Rate for Payer: Cigna Commercial |
$6,413.20
|
| Rate for Payer: First Health Commercial |
$7,340.41
|
| Rate for Payer: Humana Commercial |
$6,567.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,335.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,799.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,181.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,722.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,331.46
|
| Rate for Payer: PHCS Commercial |
$7,417.68
|
| Rate for Payer: United Healthcare All Payer |
$6,799.54
|
|
|
EXPANDER SMOOTH 15*11.5 500CC
|
Facility
|
OP
|
$7,726.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,318.03 |
| Max. Negotiated Rate |
$7,417.68 |
| Rate for Payer: Aetna Commercial |
$5,949.60
|
| Rate for Payer: Anthem Medicaid |
$2,657.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,026.86
|
| Rate for Payer: Cash Price |
$3,863.38
|
| Rate for Payer: Cigna Commercial |
$6,413.20
|
| Rate for Payer: First Health Commercial |
$7,340.41
|
| Rate for Payer: Humana Commercial |
$6,567.74
|
| Rate for Payer: Humana KY Medicaid |
$2,657.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,684.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,335.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,799.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,181.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,722.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,331.46
|
| Rate for Payer: PHCS Commercial |
$7,417.68
|
| Rate for Payer: United Healthcare All Payer |
$6,799.54
|
|
|
EXPANDER TISSUE MOD W/TABS 500
|
Facility
|
OP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPANDER TISSUE MOD W/TABS 500
|
Facility
|
IP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPANDER TISSUE MOD W/TABS 600
|
Facility
|
IP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPANDER TISSUE MOD W/TABS 600
|
Facility
|
OP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPANDER TISSUE MOD W/TABS 700
|
Facility
|
IP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPANDER TISSUE MOD W/TABS 700
|
Facility
|
OP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
EXPAREL 1.3% 1mg(133mg/10mL)VL
|
Facility
|
IP
|
$1,170.39
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
25004279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$351.12 |
| Max. Negotiated Rate |
$1,123.57 |
| Rate for Payer: Aetna Commercial |
$901.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.90
|
| Rate for Payer: Cash Price |
$585.20
|
| Rate for Payer: Cigna Commercial |
$971.42
|
| Rate for Payer: First Health Commercial |
$1,111.87
|
| Rate for Payer: Humana Commercial |
$994.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.94
|
| Rate for Payer: Ohio Health Group HMO |
$877.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,018.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.57
|
| Rate for Payer: PHCS Commercial |
$1,123.57
|
| Rate for Payer: United Healthcare All Payer |
$1,029.94
|
|
|
EXPAREL 1.3% 1mg(133mg/10mL)VL
|
Facility
|
OP
|
$1,170.39
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
25004279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1,123.57 |
| Rate for Payer: Aetna Commercial |
$901.20
|
| Rate for Payer: Anthem Medicaid |
$402.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$585.20
|
| Rate for Payer: Cash Price |
$585.20
|
| Rate for Payer: Cigna Commercial |
$971.42
|
| Rate for Payer: First Health Commercial |
$1,111.87
|
| Rate for Payer: Humana Commercial |
$994.83
|
| Rate for Payer: Humana KY Medicaid |
$402.50
|
| Rate for Payer: Humana Medicare Advantage |
$1.38
|
| Rate for Payer: Kentucky WC Medicaid |
$406.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$410.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.94
|
| Rate for Payer: Ohio Health Group HMO |
$877.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,018.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.57
|
| Rate for Payer: PHCS Commercial |
$1,123.57
|
| Rate for Payer: United Healthcare All Payer |
$1,029.94
|
|
|
EXPAREL 1.3% 1MG(266MG/20ML)VL
|
Facility
|
OP
|
$1,821.28
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
25001816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$1,748.43 |
| Rate for Payer: Aetna Commercial |
$1,402.39
|
| Rate for Payer: Anthem Medicaid |
$626.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,420.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$910.64
|
| Rate for Payer: Cash Price |
$910.64
|
| Rate for Payer: Cigna Commercial |
$1,511.66
|
| Rate for Payer: First Health Commercial |
$1,730.22
|
| Rate for Payer: Humana Commercial |
$1,548.09
|
| Rate for Payer: Humana KY Medicaid |
$626.34
|
| Rate for Payer: Humana Medicare Advantage |
$1.38
|
| Rate for Payer: Kentucky WC Medicaid |
$632.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,493.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$638.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,602.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,365.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,584.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,256.68
|
| Rate for Payer: PHCS Commercial |
$1,748.43
|
| Rate for Payer: United Healthcare All Payer |
$1,602.73
|
|
|
EXPAREL 1.3% 1MG(266MG/20ML)VL
|
Facility
|
IP
|
$1,821.28
|
|
|
Service Code
|
HCPCS J0666
|
| Hospital Charge Code |
25001816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$546.38 |
| Max. Negotiated Rate |
$1,748.43 |
| Rate for Payer: Aetna Commercial |
$1,402.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,420.60
|
| Rate for Payer: Cash Price |
$910.64
|
| Rate for Payer: Cigna Commercial |
$1,511.66
|
| Rate for Payer: First Health Commercial |
$1,730.22
|
| Rate for Payer: Humana Commercial |
$1,548.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,493.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,602.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,365.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,457.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,584.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,256.68
|
| Rate for Payer: PHCS Commercial |
$1,748.43
|
| Rate for Payer: United Healthcare All Payer |
$1,602.73
|
|
|
EXPLORATION FOREARM
|
Facility
|
OP
|
$1,385.00
|
|
|
Service Code
|
HCPCS 25999
|
| Hospital Charge Code |
76100650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$1,329.60 |
| Rate for Payer: Aetna Commercial |
$1,066.45
|
| Rate for Payer: Anthem Medicaid |
$476.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,080.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cigna Commercial |
$1,149.55
|
| Rate for Payer: First Health Commercial |
$1,315.75
|
| Rate for Payer: Humana Commercial |
$1,177.25
|
| Rate for Payer: Humana KY Medicaid |
$476.30
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$481.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,135.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,022.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$485.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,218.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,038.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,204.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$955.65
|
| Rate for Payer: PHCS Commercial |
$1,329.60
|
| Rate for Payer: United Healthcare All Payer |
$1,218.80
|
|
|
EXPLORATION FOREARM
|
Professional
|
Both
|
$1,385.00
|
|
|
Service Code
|
HCPCS 25999
|
| Hospital Charge Code |
76100650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$969.50 |
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$831.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$969.50
|
| Rate for Payer: UHCCP Medicaid |
$484.75
|
|
|
EXPLORATION FOREARM
|
Facility
|
IP
|
$1,385.00
|
|
|
Service Code
|
HCPCS 25999
|
| Hospital Charge Code |
76100650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$415.50 |
| Max. Negotiated Rate |
$1,329.60 |
| Rate for Payer: Aetna Commercial |
$1,066.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,080.30
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cigna Commercial |
$1,149.55
|
| Rate for Payer: First Health Commercial |
$1,315.75
|
| Rate for Payer: Humana Commercial |
$1,177.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,135.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,022.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$415.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,218.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,038.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,204.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$955.65
|
| Rate for Payer: PHCS Commercial |
$1,329.60
|
| Rate for Payer: United Healthcare All Payer |
$1,218.80
|
|
|
EXPLORATION FOREARM(P
|
Professional
|
Both
|
$1,385.00
|
|
|
Service Code
|
HCPCS 25999
|
| Hospital Charge Code |
761P0650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$969.50 |
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$831.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$969.50
|
| Rate for Payer: UHCCP Medicaid |
$484.75
|
|
|
EXPLORATION MAXILLARY SINUS
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 31020
|
| Hospital Charge Code |
76101144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.85 |
| Max. Negotiated Rate |
$547.53 |
| Rate for Payer: Aetna Commercial |
$484.41
|
| Rate for Payer: Ambetter Exchange |
$316.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$192.59
|
| Rate for Payer: Anthem Medicaid |
$160.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$316.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$316.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$379.26
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$472.92
|
| Rate for Payer: Healthspan PPO |
$547.53
|
| Rate for Payer: Humana Medicaid |
$160.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$442.29
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$316.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$316.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$164.07
|
| Rate for Payer: Molina Healthcare Passport |
$160.85
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$410.87
|
| Rate for Payer: UHCCP Medicaid |
$202.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$162.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$316.05
|
|
|
EXPLORATION MAXILLARY SINUS
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS 31020
|
| Hospital Charge Code |
76101144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$258.00 |
| Max. Negotiated Rate |
$825.60 |
| Rate for Payer: Aetna Commercial |
$662.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$670.80
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$713.80
|
| Rate for Payer: First Health Commercial |
$817.00
|
| Rate for Payer: Humana Commercial |
$731.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$705.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$634.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$756.80
|
| Rate for Payer: Ohio Health Group HMO |
$645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$748.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.40
|
| Rate for Payer: PHCS Commercial |
$825.60
|
| Rate for Payer: United Healthcare All Payer |
$756.80
|
|
|
EXPLORATION MAXILLARY SINUS
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS 31020
|
| Hospital Charge Code |
76101144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$662.20
|
| Rate for Payer: Anthem Medicaid |
$295.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$670.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$713.80
|
| Rate for Payer: First Health Commercial |
$817.00
|
| Rate for Payer: Humana Commercial |
$731.00
|
| Rate for Payer: Humana KY Medicaid |
$295.75
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$298.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$705.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$634.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$301.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$756.80
|
| Rate for Payer: Ohio Health Group HMO |
$645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$748.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.40
|
| Rate for Payer: PHCS Commercial |
$825.60
|
| Rate for Payer: United Healthcare All Payer |
$756.80
|
|
|
EXPLORATION MAXILLARY SINUS(P
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 31020
|
| Hospital Charge Code |
761P1144
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.85 |
| Max. Negotiated Rate |
$547.53 |
| Rate for Payer: Aetna Commercial |
$484.41
|
| Rate for Payer: Ambetter Exchange |
$316.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$192.59
|
| Rate for Payer: Anthem Medicaid |
$160.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$316.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$316.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$379.26
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$472.92
|
| Rate for Payer: Healthspan PPO |
$547.53
|
| Rate for Payer: Humana Medicaid |
$160.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$442.29
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$316.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$316.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$164.07
|
| Rate for Payer: Molina Healthcare Passport |
$160.85
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$410.87
|
| Rate for Payer: UHCCP Medicaid |
$202.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$162.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$316.05
|
|
|
EXPLORATION OF ANKLE JOINT
|
Facility
|
IP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27612
|
| Hospital Charge Code |
76100891
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
EXPLORATION OF ANKLE JOINT
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27612
|
| Hospital Charge Code |
76100891
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$428.17 |
| Max. Negotiated Rate |
$921.94 |
| Rate for Payer: Aetna Commercial |
$839.89
|
| Rate for Payer: Ambetter Exchange |
$547.07
|
| Rate for Payer: Anthem Medicaid |
$428.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$547.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$547.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$656.48
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$921.94
|
| Rate for Payer: Healthspan PPO |
$760.76
|
| Rate for Payer: Humana Medicaid |
$428.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$694.13
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$547.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$547.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$436.73
|
| Rate for Payer: Molina Healthcare Passport |
$428.17
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$711.19
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$432.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$547.07
|
|
|
EXPLORATION OF ANKLE JOINT
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27612
|
| Hospital Charge Code |
76100891
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$481.46 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem Medicaid |
$481.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| 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 |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Humana KY Medicaid |
$481.46
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$486.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
EXPLORATION OF ANKLE JOINT(P
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27612
|
| Hospital Charge Code |
761P0891
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$428.17 |
| Max. Negotiated Rate |
$921.94 |
| Rate for Payer: Aetna Commercial |
$839.89
|
| Rate for Payer: Ambetter Exchange |
$547.07
|
| Rate for Payer: Anthem Medicaid |
$428.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$547.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$547.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$656.48
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$921.94
|
| Rate for Payer: Healthspan PPO |
$760.76
|
| Rate for Payer: Humana Medicaid |
$428.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$694.13
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$547.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$547.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$436.73
|
| Rate for Payer: Molina Healthcare Passport |
$428.17
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$711.19
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$432.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$547.07
|
|
