|
ILIOINGUINAL NERVE BLOCK
|
Professional
|
Both
|
$1,410.80
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
76102316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$1,410.80 |
| Rate for Payer: Aetna Commercial |
$150.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.21
|
| Rate for Payer: Anthem Medicaid |
$44.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,410.80
|
| Rate for Payer: Cash Price |
$705.40
|
| Rate for Payer: Cash Price |
$705.40
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Healthspan PPO |
$156.20
|
| Rate for Payer: Humana Medicaid |
$44.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$120.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.51
|
| Rate for Payer: Molina Healthcare Passport |
$44.62
|
| Rate for Payer: Multiplan PHCS |
$846.48
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$987.56
|
| Rate for Payer: UHCCP Medicaid |
$43.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.07
|
|
|
ILIOINGUINAL NERVE BLOCK(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761P2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$150.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.21
|
| Rate for Payer: Anthem Medicaid |
$44.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Healthspan PPO |
$156.20
|
| Rate for Payer: Humana Medicaid |
$44.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$120.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.51
|
| Rate for Payer: Molina Healthcare Passport |
$44.62
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$43.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.07
|
|
|
ILIOINGUINAL NERVE BLOCK(T
|
Facility
|
IP
|
$1,160.80
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761T2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.90 |
| Max. Negotiated Rate |
$1,114.37 |
| Rate for Payer: Aetna Commercial |
$893.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$905.42
|
| Rate for Payer: Cash Price |
$580.40
|
| Rate for Payer: Cigna Commercial |
$963.46
|
| Rate for Payer: First Health Commercial |
$1,102.76
|
| Rate for Payer: Humana Commercial |
$986.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,021.50
|
| Rate for Payer: Ohio Health Group HMO |
$870.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.85
|
| Rate for Payer: PHCS Commercial |
$1,114.37
|
| Rate for Payer: United Healthcare All Payer |
$1,021.50
|
|
|
ILIOINGUINAL NERVE BLOCK(T
|
Facility
|
OP
|
$1,160.80
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761T2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.90 |
| Max. Negotiated Rate |
$1,114.37 |
| Rate for Payer: Aetna Commercial |
$893.82
|
| Rate for Payer: Anthem Medicaid |
$399.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$905.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$580.40
|
| Rate for Payer: Cash Price |
$580.40
|
| Rate for Payer: Cigna Commercial |
$963.46
|
| Rate for Payer: First Health Commercial |
$1,102.76
|
| Rate for Payer: Humana Commercial |
$986.68
|
| Rate for Payer: Humana KY Medicaid |
$399.20
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$403.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$407.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,021.50
|
| Rate for Payer: Ohio Health Group HMO |
$870.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.85
|
| Rate for Payer: PHCS Commercial |
$1,114.37
|
| Rate for Payer: United Healthcare All Payer |
$1,021.50
|
|
|
ILIVIA 7 VR-T DF-1 PRO MRI
|
Facility
|
OP
|
$71,980.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$9,357.40 |
| Max. Negotiated Rate |
$69,100.80 |
| Rate for Payer: Aetna Commercial |
$55,424.60
|
| Rate for Payer: Anthem Medicaid |
$24,753.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,144.40
|
| Rate for Payer: Cash Price |
$35,990.00
|
| Rate for Payer: Cigna Commercial |
$59,743.40
|
| Rate for Payer: First Health Commercial |
$68,381.00
|
| Rate for Payer: Humana Commercial |
$61,183.00
|
| Rate for Payer: Humana KY Medicaid |
$24,753.92
|
| Rate for Payer: Kentucky WC Medicaid |
$25,005.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,023.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,121.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,250.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,342.40
|
| Rate for Payer: Ohio Health Group HMO |
$53,985.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,357.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,313.80
|
| Rate for Payer: PHCS Commercial |
$69,100.80
|
| Rate for Payer: United Healthcare All Payer |
$63,342.40
|
|
|
ILIVIA 7 VR-T DF-1 PRO MRI
|
Facility
|
IP
|
$71,980.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$9,357.40 |
| Max. Negotiated Rate |
$69,100.80 |
| Rate for Payer: Aetna Commercial |
$55,424.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,144.40
|
| Rate for Payer: Cash Price |
$35,990.00
|
| Rate for Payer: Cigna Commercial |
$59,743.40
|
| Rate for Payer: First Health Commercial |
$68,381.00
|
| Rate for Payer: Humana Commercial |
$61,183.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,023.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,121.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,342.40
|
| Rate for Payer: Ohio Health Group HMO |
$53,985.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,357.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,313.80
|
| Rate for Payer: PHCS Commercial |
$69,100.80
|
| Rate for Payer: United Healthcare All Payer |
$63,342.40
|
|
|
ILIVIA NEO 7 DR-T
|
Facility
|
OP
|
$35,788.50
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$4,652.50 |
| Max. Negotiated Rate |
$34,356.96 |
| Rate for Payer: Aetna Commercial |
$27,557.14
|
| Rate for Payer: Anthem Medicaid |
$12,307.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,915.03
|
| Rate for Payer: Cash Price |
$17,894.25
|
| Rate for Payer: Cigna Commercial |
$29,704.46
|
| Rate for Payer: First Health Commercial |
$33,999.08
|
| Rate for Payer: Humana Commercial |
$30,420.22
|
| Rate for Payer: Humana KY Medicaid |
$12,307.67
|
| Rate for Payer: Kentucky WC Medicaid |
$12,432.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,346.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,411.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,736.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,554.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,493.88
|
| Rate for Payer: Ohio Health Group HMO |
$26,841.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,157.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,094.44
|
| Rate for Payer: PHCS Commercial |
$34,356.96
|
| Rate for Payer: United Healthcare All Payer |
$31,493.88
|
|
|
ILIVIA NEO 7 DR-T
|
Facility
|
IP
|
$35,788.50
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$4,652.50 |
| Max. Negotiated Rate |
$34,356.96 |
| Rate for Payer: Aetna Commercial |
$27,557.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,915.03
|
| Rate for Payer: Cash Price |
$17,894.25
|
| Rate for Payer: Cigna Commercial |
$29,704.46
|
| Rate for Payer: First Health Commercial |
$33,999.08
|
| Rate for Payer: Humana Commercial |
$30,420.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,346.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,411.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,736.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,493.88
|
| Rate for Payer: Ohio Health Group HMO |
$26,841.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,157.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,094.44
|
| Rate for Payer: PHCS Commercial |
$34,356.96
|
| Rate for Payer: United Healthcare All Payer |
$31,493.88
|
|
|
ILIZAROV DISCLIP WIRE
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$32.37
|
| Rate for Payer: First Health Commercial |
$37.05
|
| Rate for Payer: Humana Commercial |
$33.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.32
|
| Rate for Payer: Ohio Health Group HMO |
$29.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.09
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
ILIZAROV DISCLIP WIRE
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem Medicaid |
$13.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$32.37
|
| Rate for Payer: First Health Commercial |
$37.05
|
| Rate for Payer: Humana Commercial |
$33.15
|
| Rate for Payer: Humana KY Medicaid |
$13.41
|
| Rate for Payer: Kentucky WC Medicaid |
$13.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.32
|
| Rate for Payer: Ohio Health Group HMO |
$29.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.09
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
ILUMYA 1mg (100mg PFS)
|
Facility
|
IP
|
$93,944.21
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
25004213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,212.75 |
| Max. Negotiated Rate |
$90,186.44 |
| Rate for Payer: Aetna Commercial |
$72,337.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73,276.48
|
| Rate for Payer: Cash Price |
$46,972.11
|
| Rate for Payer: Cigna Commercial |
$77,973.69
|
| Rate for Payer: First Health Commercial |
$89,247.00
|
| Rate for Payer: Humana Commercial |
$79,852.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77,034.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69,330.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,183.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$82,670.90
|
| Rate for Payer: Ohio Health Group HMO |
$70,458.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,788.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,212.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,122.71
|
| Rate for Payer: PHCS Commercial |
$90,186.44
|
| Rate for Payer: United Healthcare All Payer |
$82,670.90
|
|
|
ILUMYA 1mg (100mg PFS)
|
Facility
|
OP
|
$93,944.21
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
25004213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.66 |
| Max. Negotiated Rate |
$90,186.44 |
| Rate for Payer: Aetna Commercial |
$72,337.04
|
| Rate for Payer: Anthem Medicaid |
$32,307.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$140.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73,276.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$196.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$189.88
|
| Rate for Payer: Cash Price |
$46,972.11
|
| Rate for Payer: Cash Price |
$46,972.11
|
| Rate for Payer: Cigna Commercial |
$77,973.69
|
| Rate for Payer: First Health Commercial |
$89,247.00
|
| Rate for Payer: Humana Commercial |
$79,852.58
|
| Rate for Payer: Humana KY Medicaid |
$32,307.41
|
| Rate for Payer: Humana Medicare Advantage |
$140.66
|
| Rate for Payer: Kentucky WC Medicaid |
$32,636.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77,034.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69,330.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,955.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$82,670.90
|
| Rate for Payer: Ohio Health Group HMO |
$70,458.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,788.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,212.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,122.71
|
| Rate for Payer: PHCS Commercial |
$90,186.44
|
| Rate for Payer: United Healthcare All Payer |
$82,670.90
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.30
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.30
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$16.84
|
| Rate for Payer: Healthspan PPO |
$10.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.43
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
IP
|
$4,189.04
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$544.58 |
| Max. Negotiated Rate |
$4,021.48 |
| Rate for Payer: Aetna Commercial |
$3,225.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,267.45
|
| Rate for Payer: Cash Price |
$2,094.52
|
| Rate for Payer: Cigna Commercial |
$3,476.90
|
| Rate for Payer: First Health Commercial |
$3,979.59
|
| Rate for Payer: Humana Commercial |
$3,560.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,435.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,091.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,256.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,686.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,141.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$837.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$544.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,298.60
|
| Rate for Payer: PHCS Commercial |
$4,021.48
|
| Rate for Payer: United Healthcare All Payer |
$3,686.36
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101995
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Professional
|
Both
|
$4,189.04
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.26 |
| Max. Negotiated Rate |
$4,189.04 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$165.26
|
| Rate for Payer: Anthem Medicaid |
$174.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,189.04
|
| Rate for Payer: Cash Price |
$2,094.52
|
| Rate for Payer: Cash Price |
$2,094.52
|
| Rate for Payer: Cigna Commercial |
$355.29
|
| Rate for Payer: Healthspan PPO |
$1,123.62
|
| Rate for Payer: Humana Medicaid |
$174.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$277.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.66
|
| Rate for Payer: Molina Healthcare Passport |
$174.18
|
| Rate for Payer: Multiplan PHCS |
$2,513.42
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,932.33
|
| Rate for Payer: UHCCP Medicaid |
$173.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.92
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
OP
|
$4,189.04
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$544.58 |
| Max. Negotiated Rate |
$4,021.48 |
| Rate for Payer: Aetna Commercial |
$3,225.56
|
| Rate for Payer: Anthem Medicaid |
$1,440.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,267.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,094.52
|
| Rate for Payer: Cash Price |
$2,094.52
|
| Rate for Payer: Cigna Commercial |
$3,476.90
|
| Rate for Payer: First Health Commercial |
$3,979.59
|
| Rate for Payer: Humana Commercial |
$3,560.68
|
| Rate for Payer: Humana KY Medicaid |
$1,440.61
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,455.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,435.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,091.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,469.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,686.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,141.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$837.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$544.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,298.60
|
| Rate for Payer: PHCS Commercial |
$4,021.48
|
| Rate for Payer: United Healthcare All Payer |
$3,686.36
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101995
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
IMAGE CATH FLUID COLXN VISC(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
761P1996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.26 |
| Max. Negotiated Rate |
$1,123.62 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$165.26
|
| Rate for Payer: Anthem Medicaid |
$174.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$355.29
|
| Rate for Payer: Healthspan PPO |
$1,123.62
|
| Rate for Payer: Humana Medicaid |
$174.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$277.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.66
|
| Rate for Payer: Molina Healthcare Passport |
$174.18
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$173.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.92
|
|
|
IMAGE CATH FLUID COLXN VISC(T
|
Facility
|
OP
|
$3,589.04
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
761T1996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$466.58 |
| Max. Negotiated Rate |
$3,445.48 |
| Rate for Payer: Aetna Commercial |
$2,763.56
|
| Rate for Payer: Anthem Medicaid |
$1,234.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,799.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,794.52
|
| Rate for Payer: Cash Price |
$1,794.52
|
| Rate for Payer: Cigna Commercial |
$2,978.90
|
| Rate for Payer: First Health Commercial |
$3,409.59
|
| Rate for Payer: Humana Commercial |
$3,050.68
|
| Rate for Payer: Humana KY Medicaid |
$1,234.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,246.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,648.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,259.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,158.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,691.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$717.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$466.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,112.60
|
| Rate for Payer: PHCS Commercial |
$3,445.48
|
| Rate for Payer: United Healthcare All Payer |
$3,158.36
|
|
|
IMAGE CATH FLUID COLXN VISC(T
|
Facility
|
IP
|
$3,589.04
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
761T1996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$466.58 |
| Max. Negotiated Rate |
$3,445.48 |
| Rate for Payer: Aetna Commercial |
$2,763.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,799.45
|
| Rate for Payer: Cash Price |
$1,794.52
|
| Rate for Payer: Cigna Commercial |
$2,978.90
|
| Rate for Payer: First Health Commercial |
$3,409.59
|
| Rate for Payer: Humana Commercial |
$3,050.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,648.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,076.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,158.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,691.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$717.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$466.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,112.60
|
| Rate for Payer: PHCS Commercial |
$3,445.48
|
| Rate for Payer: United Healthcare All Payer |
$3,158.36
|
|
|
IMAGING CORONARY INJECT
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
HCPCS 92556
|
| Hospital Charge Code |
47000037
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna Commercial |
$134.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$136.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$145.25
|
| Rate for Payer: First Health Commercial |
$166.25
|
| Rate for Payer: Humana Commercial |
$148.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$143.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.00
|
| Rate for Payer: Ohio Health Group HMO |
$131.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.25
|
| Rate for Payer: PHCS Commercial |
$168.00
|
| Rate for Payer: United Healthcare All Payer |
$154.00
|
|
|
IMAGING CORONARY INJECT
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 92556
|
| Hospital Charge Code |
47000037
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Aetna Commercial |
$37.46
|
| Rate for Payer: Anthem Medicaid |
$15.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$35.59
|
| Rate for Payer: Healthspan PPO |
$30.64
|
| Rate for Payer: Humana Medicaid |
$15.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$32.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$16.26
|
| Rate for Payer: Molina Healthcare Passport |
$15.94
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$16.10
|
|
