|
HOSP DISCH D MAN> 30 MINUTES
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 99239
|
| Hospital Charge Code |
51000018
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$149.40
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Humana Commercial |
$153.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.40
|
| Rate for Payer: Ohio Health Group HMO |
$135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.20
|
| Rate for Payer: PHCS Commercial |
$172.80
|
| Rate for Payer: United Healthcare All Payer |
$158.40
|
|
|
HOSP DISCH D MAN> 30 MINUTES
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 99239
|
| Hospital Charge Code |
51000018
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$152.14 |
| Rate for Payer: Aetna Commercial |
$152.14
|
| Rate for Payer: Ambetter Exchange |
$107.60
|
| Rate for Payer: Anthem Medicaid |
$72.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$107.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$107.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.12
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$144.64
|
| Rate for Payer: Healthspan PPO |
$113.10
|
| Rate for Payer: Humana Medicaid |
$72.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$107.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.35
|
| Rate for Payer: Molina Healthcare Passport |
$72.89
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$139.88
|
| Rate for Payer: UHCCP Medicaid |
$63.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$107.60
|
|
|
HOSP DISCH D MAN> 30 MINUTES(P
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 99239
|
| Hospital Charge Code |
510P0018
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$152.14 |
| Rate for Payer: Aetna Commercial |
$152.14
|
| Rate for Payer: Ambetter Exchange |
$107.60
|
| Rate for Payer: Anthem Medicaid |
$72.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$107.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$107.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.12
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$144.64
|
| Rate for Payer: Healthspan PPO |
$113.10
|
| Rate for Payer: Humana Medicaid |
$72.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$107.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.35
|
| Rate for Payer: Molina Healthcare Passport |
$72.89
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$139.88
|
| Rate for Payer: UHCCP Medicaid |
$63.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$107.60
|
|
|
HOT OR COLD PACK APP
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS 97010
|
| Hospital Charge Code |
42000005
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
HOT OR COLD PACK APP
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS 97010
|
| Hospital Charge Code |
42000005
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem Medicaid |
$21.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Humana KY Medicaid |
$21.32
|
| Rate for Payer: Kentucky WC Medicaid |
$21.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
HOT OR COLD PACKS APP
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS 97010
|
| Hospital Charge Code |
43000002
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
HOT OR COLD PACKS APP
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS 97010
|
| Hospital Charge Code |
43000002
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$59.52 |
| Rate for Payer: Aetna Commercial |
$47.74
|
| Rate for Payer: Anthem Medicaid |
$21.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.36
|
| Rate for Payer: Cash Price |
$31.00
|
| Rate for Payer: Cigna Commercial |
$51.46
|
| Rate for Payer: First Health Commercial |
$58.90
|
| Rate for Payer: Humana Commercial |
$52.70
|
| Rate for Payer: Humana KY Medicaid |
$21.32
|
| Rate for Payer: Kentucky WC Medicaid |
$21.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.56
|
| Rate for Payer: Ohio Health Group HMO |
$46.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.78
|
| Rate for Payer: PHCS Commercial |
$59.52
|
| Rate for Payer: United Healthcare All Payer |
$54.56
|
|
|
HPV 6, 11,16,18,31,33,45,52
|
Professional
|
Both
|
$905.00
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
77000017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$253.60 |
| Max. Negotiated Rate |
$633.50 |
| Rate for Payer: Anthem Medicaid |
$253.60
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Humana Medicaid |
$253.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$395.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$258.67
|
| Rate for Payer: Molina Healthcare Passport |
$253.60
|
| Rate for Payer: Multiplan PHCS |
$543.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$633.50
|
| Rate for Payer: UHCCP Medicaid |
$316.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$256.14
|
|
|
HPV 6, 11,16,18,31,33,45,52
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
77000017
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
HPV 6, 11,16,18,31,33,45,52
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
77000017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.50 |
| Max. Negotiated Rate |
$868.80 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem Medicaid |
$311.23
|
| 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: Humana KY Medicaid |
$311.23
|
| 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 |
$271.50
|
| 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
|
|
|
HPV 6, 11,16,18,31,33,45,52(T
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
770T0017
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
HPV 6, 11,16,18,31,33,45,52(T
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
HCPCS 90651
|
| Hospital Charge Code |
770T0017
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.50 |
| Max. Negotiated Rate |
$868.80 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem Medicaid |
$311.23
|
| 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: Humana KY Medicaid |
$311.23
|
| 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 |
$271.50
|
| 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
|
|
|
HPV SCREEN
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS G0476
|
| Hospital Charge Code |
30001786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
HPV SCREEN
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS G0476
|
| Hospital Charge Code |
30001786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$54.60 |
| Rate for Payer: Ambetter Exchange |
$35.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.11
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.09
|
| Rate for Payer: Multiplan PHCS |
$54.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.62
|
| Rate for Payer: UHCCP Medicaid |
$31.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.09
|
|
|
HPV SCREEN
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS G0476
|
| Hospital Charge Code |
30001786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
HPV TYPES 16 & 18 & 45
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS 87625
|
| Hospital Charge Code |
30001787
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.55 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$108.57
|
| Rate for Payer: Anthem Medicaid |
$40.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$40.55
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$117.03
|
| Rate for Payer: First Health Commercial |
$133.95
|
| Rate for Payer: Humana Commercial |
$119.85
|
| Rate for Payer: Humana KY Medicaid |
$40.55
|
| Rate for Payer: Humana Medicare Advantage |
$40.55
|
| Rate for Payer: Kentucky WC Medicaid |
$40.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.08
|
| Rate for Payer: Ohio Health Group HMO |
$105.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.29
|
| Rate for Payer: PHCS Commercial |
$135.36
|
| Rate for Payer: United Healthcare All Payer |
$124.08
|
|
|
HPV TYPES 16 & 18 & 45
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS 87625
|
| Hospital Charge Code |
30001787
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$108.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.22
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$117.03
|
| Rate for Payer: First Health Commercial |
$133.95
|
| Rate for Payer: Humana Commercial |
$119.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.08
|
| Rate for Payer: Ohio Health Group HMO |
$105.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.29
|
| Rate for Payer: PHCS Commercial |
$135.36
|
| Rate for Payer: United Healthcare All Payer |
$124.08
|
|
|
H PYLORI BREATH TEST
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 83013
|
| Hospital Charge Code |
30001782
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.65 |
| Max. Negotiated Rate |
$94.30 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem Medicaid |
$67.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$67.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$94.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.36
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Humana KY Medicaid |
$67.36
|
| Rate for Payer: Humana Medicare Advantage |
$67.36
|
| Rate for Payer: Kentucky WC Medicaid |
$68.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.65
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
H PYLORI BREATH TEST
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 83013
|
| Hospital Charge Code |
30001782
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.25
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.65
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
H PYLORI BREATH TEST
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 83013
|
| Hospital Charge Code |
30001782
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$95.13 |
| Rate for Payer: Aetna Commercial |
$67.65
|
| Rate for Payer: Ambetter Exchange |
$67.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$67.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$67.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$80.83
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$95.13
|
| Rate for Payer: Healthspan PPO |
$70.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$67.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.36
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.57
|
| Rate for Payer: UHCCP Medicaid |
$29.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$67.36
|
|
|
H PYLORI STOOL ANTIGEN
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
HCPCS 87338
|
| Hospital Charge Code |
30001349
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$115.80 |
| Rate for Payer: Aetna Commercial |
$10.73
|
| Rate for Payer: Ambetter Exchange |
$14.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$14.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$14.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.26
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$12.71
|
| Rate for Payer: Healthspan PPO |
$61.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$14.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.38
|
| Rate for Payer: Multiplan PHCS |
$115.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$18.69
|
| Rate for Payer: UHCCP Medicaid |
$67.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$8.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$14.38
|
|
|
H PYLORI STOOL ANTIGEN
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
HCPCS 87338
|
| Hospital Charge Code |
30001349
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$185.28 |
| Rate for Payer: Aetna Commercial |
$148.61
|
| Rate for Payer: Anthem Medicaid |
$14.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.38
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$160.19
|
| Rate for Payer: First Health Commercial |
$183.35
|
| Rate for Payer: Humana Commercial |
$164.05
|
| Rate for Payer: Humana KY Medicaid |
$14.38
|
| Rate for Payer: Humana Medicare Advantage |
$14.38
|
| Rate for Payer: Kentucky WC Medicaid |
$14.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.84
|
| Rate for Payer: Ohio Health Group HMO |
$144.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.17
|
| Rate for Payer: PHCS Commercial |
$185.28
|
| Rate for Payer: United Healthcare All Payer |
$169.84
|
|
|
H PYLORI STOOL ANTIGEN
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
HCPCS 87338
|
| Hospital Charge Code |
30001349
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$57.90 |
| Max. Negotiated Rate |
$185.28 |
| Rate for Payer: Aetna Commercial |
$148.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.98
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$160.19
|
| Rate for Payer: First Health Commercial |
$183.35
|
| Rate for Payer: Humana Commercial |
$164.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.84
|
| Rate for Payer: Ohio Health Group HMO |
$144.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$154.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.17
|
| Rate for Payer: PHCS Commercial |
$185.28
|
| Rate for Payer: United Healthcare All Payer |
$169.84
|
|
|
H PYLRI CLRTHMCN RST AMP PRB
|
Facility
|
OP
|
$758.55
|
|
|
Service Code
|
HCPCS 87513
|
| Hospital Charge Code |
30002078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$728.21 |
| Rate for Payer: Aetna Commercial |
$584.08
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$609.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$379.28
|
| Rate for Payer: Cash Price |
$379.28
|
| Rate for Payer: Cigna Commercial |
$629.60
|
| Rate for Payer: First Health Commercial |
$720.62
|
| Rate for Payer: Humana Commercial |
$644.77
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$622.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$667.52
|
| Rate for Payer: Ohio Health Group HMO |
$568.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$606.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.40
|
| Rate for Payer: PHCS Commercial |
$728.21
|
| Rate for Payer: United Healthcare All Payer |
$667.52
|
|
|
H PYLRI CLRTHMCN RST AMP PRB
|
Facility
|
IP
|
$758.55
|
|
|
Service Code
|
HCPCS 87513
|
| Hospital Charge Code |
30002078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$227.56 |
| Max. Negotiated Rate |
$728.21 |
| Rate for Payer: Aetna Commercial |
$584.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$609.12
|
| Rate for Payer: Cash Price |
$379.28
|
| Rate for Payer: Cigna Commercial |
$629.60
|
| Rate for Payer: First Health Commercial |
$720.62
|
| Rate for Payer: Humana Commercial |
$644.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$622.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$667.52
|
| Rate for Payer: Ohio Health Group HMO |
$568.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$606.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.40
|
| Rate for Payer: PHCS Commercial |
$728.21
|
| Rate for Payer: United Healthcare All Payer |
$667.52
|
|
