|
INVIS DIST CENT SZ 18MM
|
Facility
|
IP
|
$802.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
INVIS DIST CENT SZ 19MM
|
Facility
|
OP
|
$802.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem Medicaid |
$275.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Humana KY Medicaid |
$275.98
|
| Rate for Payer: Kentucky WC Medicaid |
$278.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
INVIS DIST CENT SZ 19MM
|
Facility
|
IP
|
$802.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
INVIS DIST CENT SZ 20MM
|
Facility
|
OP
|
$1,593.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$207.16 |
| Max. Negotiated Rate |
$1,529.79 |
| Rate for Payer: Aetna Commercial |
$1,227.02
|
| Rate for Payer: Anthem Medicaid |
$548.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,242.95
|
| Rate for Payer: Cash Price |
$796.76
|
| Rate for Payer: Cigna Commercial |
$1,322.63
|
| Rate for Payer: First Health Commercial |
$1,513.85
|
| Rate for Payer: Humana Commercial |
$1,354.50
|
| Rate for Payer: Humana KY Medicaid |
$548.01
|
| Rate for Payer: Kentucky WC Medicaid |
$553.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,306.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,176.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$478.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$559.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,402.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,195.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.99
|
| Rate for Payer: PHCS Commercial |
$1,529.79
|
| Rate for Payer: United Healthcare All Payer |
$1,402.31
|
|
|
INVIS DIST CENT SZ 20MM
|
Facility
|
IP
|
$1,593.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$207.16 |
| Max. Negotiated Rate |
$1,529.79 |
| Rate for Payer: Aetna Commercial |
$1,227.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,242.95
|
| Rate for Payer: Cash Price |
$796.76
|
| Rate for Payer: Cigna Commercial |
$1,322.63
|
| Rate for Payer: First Health Commercial |
$1,513.85
|
| Rate for Payer: Humana Commercial |
$1,354.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,306.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,176.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$478.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,402.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,195.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.99
|
| Rate for Payer: PHCS Commercial |
$1,529.79
|
| Rate for Payer: United Healthcare All Payer |
$1,402.31
|
|
|
INVIS DIST CENT SZ 21MM
|
Facility
|
OP
|
$1,593.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$207.16 |
| Max. Negotiated Rate |
$1,529.79 |
| Rate for Payer: Aetna Commercial |
$1,227.02
|
| Rate for Payer: Anthem Medicaid |
$548.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,242.95
|
| Rate for Payer: Cash Price |
$796.76
|
| Rate for Payer: Cigna Commercial |
$1,322.63
|
| Rate for Payer: First Health Commercial |
$1,513.85
|
| Rate for Payer: Humana Commercial |
$1,354.50
|
| Rate for Payer: Humana KY Medicaid |
$548.01
|
| Rate for Payer: Kentucky WC Medicaid |
$553.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,306.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,176.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$478.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$559.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,402.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,195.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.99
|
| Rate for Payer: PHCS Commercial |
$1,529.79
|
| Rate for Payer: United Healthcare All Payer |
$1,402.31
|
|
|
INVIS DIST CENT SZ 21MM
|
Facility
|
IP
|
$1,593.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$207.16 |
| Max. Negotiated Rate |
$1,529.79 |
| Rate for Payer: Aetna Commercial |
$1,227.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,242.95
|
| Rate for Payer: Cash Price |
$796.76
|
| Rate for Payer: Cigna Commercial |
$1,322.63
|
| Rate for Payer: First Health Commercial |
$1,513.85
|
| Rate for Payer: Humana Commercial |
$1,354.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,306.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,176.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$478.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,402.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,195.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$493.99
|
| Rate for Payer: PHCS Commercial |
$1,529.79
|
| Rate for Payer: United Healthcare All Payer |
$1,402.31
|
|
|
INVIS DIST CENT SZ 8MM
|
Facility
|
OP
|
$802.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem Medicaid |
$275.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Humana KY Medicaid |
$275.98
|
| Rate for Payer: Kentucky WC Medicaid |
$278.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
INVIS DIST CENT SZ 8MM
|
Facility
|
IP
|
$802.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
INVIS DIST CENT SZ 9MM
|
Facility
|
IP
|
$1,799.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.90 |
| Max. Negotiated Rate |
$1,727.25 |
| Rate for Payer: Aetna Commercial |
$1,385.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,403.39
|
| Rate for Payer: Cash Price |
$899.61
|
| Rate for Payer: Cigna Commercial |
$1,493.35
|
| Rate for Payer: First Health Commercial |
$1,709.26
|
| Rate for Payer: Humana Commercial |
$1,529.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,475.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,327.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,583.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,349.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$359.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$557.76
|
| Rate for Payer: PHCS Commercial |
$1,727.25
|
| Rate for Payer: United Healthcare All Payer |
$1,583.31
|
|
|
INVIS DIST CENT SZ 9MM
|
Facility
|
OP
|
$1,799.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.90 |
| Max. Negotiated Rate |
$1,727.25 |
| Rate for Payer: Aetna Commercial |
$1,385.40
|
| Rate for Payer: Anthem Medicaid |
$618.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,403.39
|
| Rate for Payer: Cash Price |
$899.61
|
| Rate for Payer: Cigna Commercial |
$1,493.35
|
| Rate for Payer: First Health Commercial |
$1,709.26
|
| Rate for Payer: Humana Commercial |
$1,529.34
|
| Rate for Payer: Humana KY Medicaid |
$618.75
|
| Rate for Payer: Kentucky WC Medicaid |
$625.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,475.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,327.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$539.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,583.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,349.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$359.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$557.76
|
| Rate for Payer: PHCS Commercial |
$1,727.25
|
| Rate for Payer: United Healthcare All Payer |
$1,583.31
|
|
|
INVOKANA 100MG TABLET
|
Facility
|
IP
|
$36.95
|
|
|
Service Code
|
NDC 50458014030
|
| Hospital Charge Code |
25000791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$35.47 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.82
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna Commercial |
$30.67
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: Humana Commercial |
$31.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.52
|
| Rate for Payer: Ohio Health Group HMO |
$27.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.45
|
| Rate for Payer: PHCS Commercial |
$35.47
|
| Rate for Payer: United Healthcare All Payer |
$32.52
|
|
|
INVOKANA 100MG TABLET
|
Facility
|
OP
|
$36.95
|
|
|
Service Code
|
NDC 50458014030
|
| Hospital Charge Code |
25000791
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$35.47 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Anthem Medicaid |
$12.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.82
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna Commercial |
$30.67
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: Humana Commercial |
$31.41
|
| Rate for Payer: Humana KY Medicaid |
$12.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.52
|
| Rate for Payer: Ohio Health Group HMO |
$27.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.45
|
| Rate for Payer: PHCS Commercial |
$35.47
|
| Rate for Payer: United Healthcare All Payer |
$32.52
|
|
|
INVOKANA 300 MG TABLET
|
Facility
|
OP
|
$36.95
|
|
|
Service Code
|
NDC 50458014130
|
| Hospital Charge Code |
25000792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$35.47 |
| Rate for Payer: Anthem Medicaid |
$12.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.82
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna Commercial |
$30.67
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: Humana Commercial |
$31.41
|
| Rate for Payer: Humana KY Medicaid |
$12.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.52
|
| Rate for Payer: Ohio Health Group HMO |
$27.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.45
|
| Rate for Payer: PHCS Commercial |
$35.47
|
| Rate for Payer: United Healthcare All Payer |
$32.52
|
| Rate for Payer: Aetna Commercial |
$28.45
|
|
|
INVOKANA 300 MG TABLET
|
Facility
|
IP
|
$36.95
|
|
|
Service Code
|
NDC 50458014130
|
| Hospital Charge Code |
25000792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$35.47 |
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.82
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cigna Commercial |
$30.67
|
| Rate for Payer: First Health Commercial |
$35.10
|
| Rate for Payer: Humana Commercial |
$31.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.52
|
| Rate for Payer: Ohio Health Group HMO |
$27.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.45
|
| Rate for Payer: PHCS Commercial |
$35.47
|
| Rate for Payer: United Healthcare All Payer |
$32.52
|
|
|
IOD I131 SODIOD CAPTHER EAMLCR
|
Professional
|
Both
|
$51.00
|
|
| Hospital Charge Code |
34000053
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$51.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Multiplan PHCS |
$30.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.70
|
| Rate for Payer: UHCCP Medicaid |
$17.85
|
|
|
IOD I131 SODIOD CAPTHER EAMLCR
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
34000053
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$17.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.81
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Humana KY Medicaid |
$17.54
|
| Rate for Payer: Humana Medicare Advantage |
$21.34
|
| Rate for Payer: Kentucky WC Medicaid |
$17.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
IOD I131 SODIOD CAPTHER EAMLCR
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
34000053
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
IOD I131 SODIOD CAPTHER EAMLCR
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
340T0053
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$17.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.81
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Humana KY Medicaid |
$17.54
|
| Rate for Payer: Humana Medicare Advantage |
$21.34
|
| Rate for Payer: Kentucky WC Medicaid |
$17.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
IOD I131 SODIOD CAPTHER EAMLCR
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS A9517
|
| Hospital Charge Code |
340T0053
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
IO MAP OF SENT LYMPH NODE
|
Professional
|
Both
|
$3,679.19
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.87 |
| Max. Negotiated Rate |
$3,679.19 |
| Rate for Payer: Aetna Commercial |
$224.23
|
| Rate for Payer: Anthem Medicaid |
$119.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,679.19
|
| Rate for Payer: Cash Price |
$1,839.60
|
| Rate for Payer: Cash Price |
$1,839.60
|
| Rate for Payer: Cigna Commercial |
$233.32
|
| Rate for Payer: Healthspan PPO |
$134.66
|
| Rate for Payer: Humana Medicaid |
$119.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$178.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.27
|
| Rate for Payer: Molina Healthcare Passport |
$119.87
|
| Rate for Payer: Multiplan PHCS |
$2,207.51
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,575.43
|
| Rate for Payer: UHCCP Medicaid |
$1,287.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.07
|
|
|
IO MAP OF SENT LYMPH NODE
|
Facility
|
OP
|
$3,679.19
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$478.29 |
| Max. Negotiated Rate |
$3,532.02 |
| Rate for Payer: Aetna Commercial |
$2,832.98
|
| Rate for Payer: Anthem Medicaid |
$1,265.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,869.77
|
| Rate for Payer: Cash Price |
$1,839.60
|
| Rate for Payer: Cigna Commercial |
$3,053.73
|
| Rate for Payer: First Health Commercial |
$3,495.23
|
| Rate for Payer: Humana Commercial |
$3,127.31
|
| Rate for Payer: Humana KY Medicaid |
$1,265.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,278.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,016.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,103.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,290.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,237.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,759.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$735.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,140.55
|
| Rate for Payer: PHCS Commercial |
$3,532.02
|
| Rate for Payer: United Healthcare All Payer |
$3,237.69
|
|
|
IO MAP OF SENT LYMPH NODE
|
Facility
|
IP
|
$3,679.19
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$478.29 |
| Max. Negotiated Rate |
$3,532.02 |
| Rate for Payer: Aetna Commercial |
$2,832.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,869.77
|
| Rate for Payer: Cash Price |
$1,839.60
|
| Rate for Payer: Cigna Commercial |
$3,053.73
|
| Rate for Payer: First Health Commercial |
$3,495.23
|
| Rate for Payer: Humana Commercial |
$3,127.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,016.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,103.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,237.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,759.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$735.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,140.55
|
| Rate for Payer: PHCS Commercial |
$3,532.02
|
| Rate for Payer: United Healthcare All Payer |
$3,237.69
|
|
|
IO MAP OF SENT LYMPH NODE(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
761P1613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$233.32 |
| Rate for Payer: Aetna Commercial |
$224.23
|
| Rate for Payer: Anthem Medicaid |
$119.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$233.32
|
| Rate for Payer: Healthspan PPO |
$134.66
|
| Rate for Payer: Humana Medicaid |
$119.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$178.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.27
|
| Rate for Payer: Molina Healthcare Passport |
$119.87
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.07
|
|
|
IO MAP OF SENT LYMPH NODE(T
|
Facility
|
OP
|
$3,529.19
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
761T1613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$458.79 |
| Max. Negotiated Rate |
$3,388.02 |
| Rate for Payer: Aetna Commercial |
$2,717.48
|
| Rate for Payer: Anthem Medicaid |
$1,213.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,752.77
|
| Rate for Payer: Cash Price |
$1,764.60
|
| Rate for Payer: Cigna Commercial |
$2,929.23
|
| Rate for Payer: First Health Commercial |
$3,352.73
|
| Rate for Payer: Humana Commercial |
$2,999.81
|
| Rate for Payer: Humana KY Medicaid |
$1,213.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,226.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,893.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,604.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,058.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,238.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,105.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,646.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$705.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.05
|
| Rate for Payer: PHCS Commercial |
$3,388.02
|
| Rate for Payer: United Healthcare All Payer |
$3,105.69
|
|
