|
OUTPATIENT EAPG 00331: LEVEL I DIAGNOSTIC NUCLEAR MEDICINE
|
Facility
OP
|
$135.33
|
|
|
Service Code
|
EAPG 00331
|
| Hospital Charge Code |
EAPG 00331
|
| Min. Negotiated Rate |
$135.33 |
| Max. Negotiated Rate |
$135.33 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$135.33
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$135.33
|
|
|
OUTPATIENT EAPG 00332: LEVEL II DIAGNOSTIC NUCLEAR MEDICINE
|
Facility
OP
|
$309.06
|
|
|
Service Code
|
EAPG 00332
|
| Hospital Charge Code |
EAPG 00332
|
| Min. Negotiated Rate |
$309.06 |
| Max. Negotiated Rate |
$309.06 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$309.06
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$309.06
|
|
|
OUTPATIENT EAPG 00335: LEVEL I BRACHYTHERAPY SOURCES
|
Facility
OP
|
$396.39
|
|
|
Service Code
|
EAPG 00335
|
| Hospital Charge Code |
EAPG 00335
|
| Min. Negotiated Rate |
$396.39 |
| Max. Negotiated Rate |
$396.39 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$396.39
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$396.39
|
|
|
OUTPATIENT EAPG 00336: LEVEL II BRACHYTHERAPY SOURCES
|
Facility
OP
|
$465.24
|
|
|
Service Code
|
EAPG 00336
|
| Hospital Charge Code |
EAPG 00336
|
| Min. Negotiated Rate |
$465.24 |
| Max. Negotiated Rate |
$465.24 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$465.24
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$465.24
|
|
|
OUTPATIENT EAPG 00337: LEVEL III BRACHYTHERAPY SOURCES
|
Facility
OP
|
$2,353.03
|
|
|
Service Code
|
EAPG 00337
|
| Hospital Charge Code |
EAPG 00337
|
| Min. Negotiated Rate |
$2,353.03 |
| Max. Negotiated Rate |
$2,353.03 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$2,353.03
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$2,353.03
|
|
|
OUTPATIENT EAPG 00340: THERAPEUTIC NUCLEAR MEDICINE
|
Facility
OP
|
$176.74
|
|
|
Service Code
|
EAPG 00340
|
| Hospital Charge Code |
EAPG 00340
|
| Min. Negotiated Rate |
$176.74 |
| Max. Negotiated Rate |
$176.74 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$176.74
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$176.74
|
|
|
OUTPATIENT EAPG 00343: LEVEL I RADIATION THERAPY
|
Facility
OP
|
$132.00
|
|
|
Service Code
|
EAPG 00343
|
| Hospital Charge Code |
EAPG 00343
|
| Min. Negotiated Rate |
$132.00 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$132.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$132.00
|
|
|
OUTPATIENT EAPG 00346: RADIOSURGERY
|
Facility
OP
|
$2,030.77
|
|
|
Service Code
|
EAPG 00346
|
| Hospital Charge Code |
EAPG 00346
|
| Min. Negotiated Rate |
$2,030.77 |
| Max. Negotiated Rate |
$2,030.77 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$2,030.77
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$2,030.77
|
|
|
OUTPATIENT EAPG 00347: LEVEL II RADIATION THERAPY
|
Facility
OP
|
$344.84
|
|
|
Service Code
|
EAPG 00347
|
| Hospital Charge Code |
EAPG 00347
|
| Min. Negotiated Rate |
$344.84 |
| Max. Negotiated Rate |
$344.84 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$344.84
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$344.84
|
|
|
OUTPATIENT EAPG 00348: LEVEL III RADIATION THERAPY
|
Facility
OP
|
$898.45
|
|
|
Service Code
|
EAPG 00348
|
| Hospital Charge Code |
EAPG 00348
|
| Min. Negotiated Rate |
$898.45 |
| Max. Negotiated Rate |
$898.45 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$898.45
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$898.45
|
|
|
OUTPATIENT EAPG 00350: LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00350
|
| Hospital Charge Code |
EAPG 00350
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00351: LEVEL II ADJUNCTIVE GENERAL DENTAL SERVICES
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00351
|
| Hospital Charge Code |
EAPG 00351
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00352: LEVEL I PERIODONTICS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00352
|
| Hospital Charge Code |
EAPG 00352
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00353: LEVEL I PROSTHODONTICS, FIXED
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00353
|
| Hospital Charge Code |
EAPG 00353
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00354: LEVEL II PROSTHODONTICS, FIXED
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00354
|
| Hospital Charge Code |
EAPG 00354
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00355: LEVEL III PROSTHODONTICS, FIXED
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00355
|
| Hospital Charge Code |
EAPG 00355
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00356: LEVEL I PROSTHODONTICS, REMOVABLE
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00356
|
| Hospital Charge Code |
EAPG 00356
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00357: LEVEL II PROSTHODONTICS, REMOVABLE
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00357
|
| Hospital Charge Code |
EAPG 00357
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00358: LEVEL III PROSTHODONTICS, REMOVABLE
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00358
|
| Hospital Charge Code |
EAPG 00358
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00359: LEVEL I MAXILLOFACIAL PROSTHETICS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00359
|
| Hospital Charge Code |
EAPG 00359
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00360: LEVEL II MAXILLOFACIAL PROSTHETICS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00360
|
| Hospital Charge Code |
EAPG 00360
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00361: LEVEL I DENTAL RESTORATIONS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00361
|
| Hospital Charge Code |
EAPG 00361
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00362: LEVEL II DENTAL RESTORATIONS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00362
|
| Hospital Charge Code |
EAPG 00362
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00363: LEVEL III DENTAL RESTORATION
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00363
|
| Hospital Charge Code |
EAPG 00363
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
|
OUTPATIENT EAPG 00364: LEVEL I ENDODONTICS
|
Facility
OP
|
$1,192.00
|
|
|
Service Code
|
EAPG 00364
|
| Hospital Charge Code |
EAPG 00364
|
| Min. Negotiated Rate |
$1,192.00 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Buckeye Health Medicaid OOS |
$1,192.00
|
| Rate for Payer: Molina Healthcare of OH Medicare |
$1,192.00
|
|
