|
INIT HOSPITAL CARE LEVEL 2(P
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
HCPCS 99222
|
| Hospital Charge Code |
510P0012
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$194.52 |
| Rate for Payer: Aetna Commercial |
$194.52
|
| Rate for Payer: Ambetter Exchange |
$122.69
|
| Rate for Payer: Anthem Medicaid |
$85.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.23
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$182.25
|
| Rate for Payer: Healthspan PPO |
$144.60
|
| Rate for Payer: Humana Medicaid |
$85.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$181.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$87.31
|
| Rate for Payer: Molina Healthcare Passport |
$85.60
|
| Rate for Payer: Multiplan PHCS |
$126.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.50
|
| Rate for Payer: UHCCP Medicaid |
$73.50
|
| Rate for Payer: United Healthcare Non-Options |
$133.97
|
| Rate for Payer: United Healthcare Options |
$109.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$86.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.69
|
|
|
INIT HOSPITAL CARE LEVEL 3
|
Professional
|
Both
|
$295.00
|
|
|
Service Code
|
HCPCS 99223
|
| Hospital Charge Code |
51000013
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.25 |
| Max. Negotiated Rate |
$285.83 |
| Rate for Payer: Aetna Commercial |
$285.83
|
| Rate for Payer: Ambetter Exchange |
$163.53
|
| Rate for Payer: Anthem Medicaid |
$119.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$163.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$163.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.24
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$266.01
|
| Rate for Payer: Healthspan PPO |
$212.47
|
| Rate for Payer: Humana Medicaid |
$119.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$266.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$163.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.64
|
| Rate for Payer: Molina Healthcare Passport |
$119.25
|
| Rate for Payer: Multiplan PHCS |
$177.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.59
|
| Rate for Payer: UHCCP Medicaid |
$103.25
|
| Rate for Payer: United Healthcare Non-Options |
$196.85
|
| Rate for Payer: United Healthcare Options |
$161.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$163.53
|
|
|
INIT HOSPITAL CARE LEVEL 3
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
HCPCS 99223
|
| Hospital Charge Code |
51000013
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem Medicaid |
$101.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Humana KY Medicaid |
$101.45
|
| Rate for Payer: Kentucky WC Medicaid |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.55
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
INIT HOSPITAL CARE LEVEL 3
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
HCPCS 99223
|
| Hospital Charge Code |
51000013
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.55
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
INIT HOSPITAL CARE LEVEL 3(P
|
Professional
|
Both
|
$295.00
|
|
|
Service Code
|
HCPCS 99223
|
| Hospital Charge Code |
510P0013
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.25 |
| Max. Negotiated Rate |
$285.83 |
| Rate for Payer: Aetna Commercial |
$285.83
|
| Rate for Payer: Ambetter Exchange |
$163.53
|
| Rate for Payer: Anthem Medicaid |
$119.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$163.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$163.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.24
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$266.01
|
| Rate for Payer: Healthspan PPO |
$212.47
|
| Rate for Payer: Humana Medicaid |
$119.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$266.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$163.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.64
|
| Rate for Payer: Molina Healthcare Passport |
$119.25
|
| Rate for Payer: Multiplan PHCS |
$177.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.59
|
| Rate for Payer: UHCCP Medicaid |
$103.25
|
| Rate for Payer: United Healthcare Non-Options |
$196.85
|
| Rate for Payer: United Healthcare Options |
$161.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$163.53
|
|
|
INITIAL FOOT EXAM PT LOPS
|
Facility
|
IP
|
$325.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
51000341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
INITIAL FOOT EXAM PT LOPS
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
51000341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.17 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$70.77
|
| Rate for Payer: Ambetter Exchange |
$37.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.60
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$37.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.17
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.32
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.17
|
|
|
INITIAL FOOT EXAM PT LOPS
|
Facility
|
OP
|
$325.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
51000341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$111.77 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem Medicaid |
$111.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Humana KY Medicaid |
$111.77
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$112.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
INITIAL FOOT EXAM PT LOPS (P
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
510P0341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$70.77 |
| Rate for Payer: Aetna Commercial |
$70.77
|
| Rate for Payer: Ambetter Exchange |
$37.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.60
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$37.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.17
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$48.32
|
| Rate for Payer: UHCCP Medicaid |
$29.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.17
|
|
|
INITIAL FOOT EXAM PT LOPS(T
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
510T0341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$187.20
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.60
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
INITIAL FOOT EXAM PT LOPS(T
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS G0245
|
| Hospital Charge Code |
510T0341
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.54 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem Medicaid |
$82.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$187.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Humana KY Medicaid |
$82.54
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$83.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.60
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 98925
|
| Hospital Charge Code |
51000142
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Ambetter Exchange |
$21.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$11.94
|
| Rate for Payer: Anthem Medicaid |
$20.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$21.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$21.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.78
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$38.26
|
| Rate for Payer: Humana Medicaid |
$20.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$21.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.81
|
| Rate for Payer: Molina Healthcare Passport |
$20.40
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$27.92
|
| Rate for Payer: UHCCP Medicaid |
$12.54
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$21.48
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 98925
|
| Hospital Charge Code |
510P0142
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$22.33
|
| Rate for Payer: Ambetter Exchange |
$21.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$11.94
|
| Rate for Payer: Anthem Medicaid |
$20.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$21.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$21.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.78
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$38.26
|
| Rate for Payer: Humana Medicaid |
$20.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$21.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.81
|
| Rate for Payer: Molina Healthcare Passport |
$20.40
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$27.92
|
| Rate for Payer: UHCCP Medicaid |
$12.54
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$21.48
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
50000187
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.35 |
| Max. Negotiated Rate |
$174.69 |
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Ambetter Exchange |
$122.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.30
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.75
|
| Rate for Payer: Multiplan PHCS |
$156.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.57
|
| Rate for Payer: UHCCP Medicaid |
$91.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.75
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS 98925
|
| Hospital Charge Code |
51000142
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
INITIAL PREVENTIVE EXAM
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS 98925
|
| Hospital Charge Code |
51000142
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.38 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$32.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.56
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.97
|
| Rate for Payer: Humana Medicare Advantage |
$23.38
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
INITIAL PREVENTIVE EXAM (P
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
500P0187
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.35 |
| Max. Negotiated Rate |
$174.69 |
| Rate for Payer: Aetna Commercial |
$144.95
|
| Rate for Payer: Ambetter Exchange |
$122.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.30
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.75
|
| Rate for Payer: Multiplan PHCS |
$156.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.57
|
| Rate for Payer: UHCCP Medicaid |
$91.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.75
|
|
|
INITIATE AMB INFUS CHEMO PUMP
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS 96416
|
| Hospital Charge Code |
33100008
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$158.70 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$460.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.01
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
INITIATE AMB INFUS CHEMO PUMP
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS 96416
|
| Hospital Charge Code |
33100008
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$181.92 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem Medicaid |
$181.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$306.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$429.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$413.73
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Humana KY Medicaid |
$181.92
|
| Rate for Payer: Humana Medicare Advantage |
$306.47
|
| Rate for Payer: Kentucky WC Medicaid |
$183.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$460.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.01
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
INITIATION NCHEMO INFUS PUMP
|
Facility
|
IP
|
$499.00
|
|
| Hospital Charge Code |
26000016
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$149.70 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$434.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$344.31
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
INITIATION NCHEMO INFUS PUMP
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS C8957
|
| Hospital Charge Code |
26000013
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$306.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$429.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$413.73
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Humana Medicare Advantage |
$306.47
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
INITIATION NCHEMO INFUS PUMP
|
Facility
|
OP
|
$499.00
|
|
| Hospital Charge Code |
26000016
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$149.70 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$434.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$344.31
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
INITIATION NCHEMO INFUS PUMP
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS C8957
|
| Hospital Charge Code |
26000013
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$152.70 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
INIT NB EM PER DAY HOSP
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
HCPCS 99460
|
| Hospital Charge Code |
51000117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.20 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
INIT NB EM PER DAY HOSP
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
HCPCS 99460
|
| Hospital Charge Code |
51000117
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem Medicaid |
$104.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Humana KY Medicaid |
$104.55
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$105.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
