|
IO MAP OF SENT LYMPH NODE(T
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
IONIZED CALCIUM PROFILE
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
30000260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem Medicaid |
$13.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Humana KY Medicaid |
$13.68
|
| Rate for Payer: Humana Medicare Advantage |
$13.68
|
| Rate for Payer: Kentucky WC Medicaid |
$13.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
IONIZED CALCIUM PROFILE
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
30000260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.55 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.40
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.85
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
43000009
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem Medicaid |
$49.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.54
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Humana KY Medicaid |
$49.18
|
| Rate for Payer: Kentucky WC Medicaid |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
43000009
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.54
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
42000013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem Medicaid |
$49.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.54
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Humana KY Medicaid |
$49.18
|
| Rate for Payer: Kentucky WC Medicaid |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
42000013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.54
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IOPIDINE(APRACLONIDIN)0.5%/5ML
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 61314066505
|
| Hospital Charge Code |
25003800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.33
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$2.48
|
| Rate for Payer: First Health Commercial |
$2.84
|
| Rate for Payer: Humana Commercial |
$2.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.63
|
| Rate for Payer: Ohio Health Group HMO |
$2.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.93
|
| Rate for Payer: PHCS Commercial |
$2.87
|
| Rate for Payer: United Healthcare All Payer |
$2.63
|
|
|
IOPIDINE(APRACLONIDIN)0.5%/5ML
|
Facility
|
OP
|
$2.99
|
|
|
Service Code
|
NDC 61314066505
|
| Hospital Charge Code |
25003800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: Anthem Medicaid |
$1.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.33
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$2.48
|
| Rate for Payer: First Health Commercial |
$2.84
|
| Rate for Payer: Humana Commercial |
$2.54
|
| Rate for Payer: Humana KY Medicaid |
$1.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.63
|
| Rate for Payer: Ohio Health Group HMO |
$2.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.93
|
| Rate for Payer: PHCS Commercial |
$2.87
|
| Rate for Payer: United Healthcare All Payer |
$2.63
|
|
|
IOPODINE(APRACLONIDINE)1%/.1ML
|
Facility
|
IP
|
$65.73
|
|
|
Service Code
|
NDC 82667020001
|
| Hospital Charge Code |
25003127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.54 |
| Max. Negotiated Rate |
$63.10 |
| Rate for Payer: Aetna Commercial |
$50.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.27
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Cigna Commercial |
$54.56
|
| Rate for Payer: First Health Commercial |
$62.44
|
| Rate for Payer: Humana Commercial |
$55.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.84
|
| Rate for Payer: Ohio Health Group HMO |
$49.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.38
|
| Rate for Payer: PHCS Commercial |
$63.10
|
| Rate for Payer: United Healthcare All Payer |
$57.84
|
|
|
IOPODINE(APRACLONIDINE)1%/.1ML
|
Facility
|
OP
|
$65.73
|
|
|
Service Code
|
NDC 82667020001
|
| Hospital Charge Code |
25003127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.54 |
| Max. Negotiated Rate |
$63.10 |
| Rate for Payer: Aetna Commercial |
$50.61
|
| Rate for Payer: Anthem Medicaid |
$22.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.27
|
| Rate for Payer: Cash Price |
$32.87
|
| Rate for Payer: Cigna Commercial |
$54.56
|
| Rate for Payer: First Health Commercial |
$62.44
|
| Rate for Payer: Humana Commercial |
$55.87
|
| Rate for Payer: Humana KY Medicaid |
$22.60
|
| Rate for Payer: Kentucky WC Medicaid |
$22.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.84
|
| Rate for Payer: Ohio Health Group HMO |
$49.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.38
|
| Rate for Payer: PHCS Commercial |
$63.10
|
| Rate for Payer: United Healthcare All Payer |
$57.84
|
|
|
IPACK BLOCK
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102832
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Anthem Medicaid |
$2,800.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$2,800.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,856.00
|
| Rate for Payer: Molina Healthcare Passport |
$2,800.00
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,828.00
|
|
|
IPACK BLOCK
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102832
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.76
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
IPACK BLOCK
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102832
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
IP/OBS CNSLTJ NEW/EST LOW 45
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 99253
|
| Hospital Charge Code |
51000334
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$181.71 |
| Rate for Payer: Aetna Commercial |
$181.71
|
| Rate for Payer: Anthem Medicaid |
$74.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$166.39
|
| Rate for Payer: Healthspan PPO |
$135.08
|
| Rate for Payer: Humana Medicaid |
$74.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$76.24
|
| Rate for Payer: Molina Healthcare Passport |
$74.75
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$75.50
|
|
|
IP/OBS CNSLTJ NEW/EST LOW 45(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 99253
|
| Hospital Charge Code |
510P0334
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$181.71 |
| Rate for Payer: Aetna Commercial |
$181.71
|
| Rate for Payer: Anthem Medicaid |
$74.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$166.39
|
| Rate for Payer: Healthspan PPO |
$135.08
|
| Rate for Payer: Humana Medicaid |
$74.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$76.24
|
| Rate for Payer: Molina Healthcare Passport |
$74.75
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$75.50
|
|
|
IP/OBS CNSLTJ NEW/EST MOD 60
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99254
|
| Hospital Charge Code |
51000335
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$261.81 |
| Rate for Payer: Aetna Commercial |
$261.81
|
| Rate for Payer: Anthem Medicaid |
$107.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$239.49
|
| Rate for Payer: Healthspan PPO |
$194.62
|
| Rate for Payer: Humana Medicaid |
$107.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.65
|
| Rate for Payer: Molina Healthcare Passport |
$107.50
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.58
|
|
|
IP/OBS CNSLTJ NEW/EST MOD 60(P
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99254
|
| Hospital Charge Code |
510P0335
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$261.81 |
| Rate for Payer: Aetna Commercial |
$261.81
|
| Rate for Payer: Anthem Medicaid |
$107.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$239.49
|
| Rate for Payer: Healthspan PPO |
$194.62
|
| Rate for Payer: Humana Medicaid |
$107.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.65
|
| Rate for Payer: Molina Healthcare Passport |
$107.50
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.58
|
|
|
IP/OBS CONSLTJ NEW/EST HI 80
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99255
|
| Hospital Charge Code |
51000336
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.75 |
| Max. Negotiated Rate |
$319.75 |
| Rate for Payer: Aetna Commercial |
$319.75
|
| Rate for Payer: Anthem Medicaid |
$148.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.00
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$298.27
|
| Rate for Payer: Healthspan PPO |
$237.69
|
| Rate for Payer: Humana Medicaid |
$148.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$151.16
|
| Rate for Payer: Molina Healthcare Passport |
$148.20
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$71.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.68
|
|
|
IP/OBS CONSLTJ NEW/EST HI 80(P
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99255
|
| Hospital Charge Code |
510P0336
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.75 |
| Max. Negotiated Rate |
$319.75 |
| Rate for Payer: Aetna Commercial |
$319.75
|
| Rate for Payer: Anthem Medicaid |
$148.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.00
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$298.27
|
| Rate for Payer: Healthspan PPO |
$237.69
|
| Rate for Payer: Humana Medicaid |
$148.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$151.16
|
| Rate for Payer: Molina Healthcare Passport |
$148.20
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$71.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.68
|
|
|
IP/OBS CONSLTJ NEW/EST SF 35
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
HCPCS 99252
|
| Hospital Charge Code |
51000333
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$120.30 |
| Rate for Payer: Aetna Commercial |
$120.30
|
| Rate for Payer: Anthem Medicaid |
$55.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.00
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$112.37
|
| Rate for Payer: Healthspan PPO |
$89.43
|
| Rate for Payer: Humana Medicaid |
$55.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.84
|
| Rate for Payer: Molina Healthcare Passport |
$55.73
|
| Rate for Payer: Multiplan PHCS |
$57.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.50
|
| Rate for Payer: UHCCP Medicaid |
$33.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.29
|
|
|
IP/OBS CONSLTJ NEW/EST SF 35(P
|
Professional
|
Both
|
$95.00
|
|
|
Service Code
|
HCPCS 99252
|
| Hospital Charge Code |
510P0333
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$120.30 |
| Rate for Payer: Aetna Commercial |
$120.30
|
| Rate for Payer: Anthem Medicaid |
$55.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.00
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$112.37
|
| Rate for Payer: Healthspan PPO |
$89.43
|
| Rate for Payer: Humana Medicaid |
$55.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.84
|
| Rate for Payer: Molina Healthcare Passport |
$55.73
|
| Rate for Payer: Multiplan PHCS |
$57.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.50
|
| Rate for Payer: UHCCP Medicaid |
$33.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.29
|
|
|
IPS FACILITY CHARGE
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000315
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.83 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem Medicaid |
$134.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Humana KY Medicaid |
$134.46
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$135.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.21
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
IPS FACILITY CHARGE
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000315
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.83 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.21
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
IR ABLATE BONE PERCUT RF
|
Professional
|
Both
|
$3,900.00
|
|
|
Service Code
|
HCPCS 20982
|
| Hospital Charge Code |
320P1008
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$298.81 |
| Max. Negotiated Rate |
$4,620.02 |
| Rate for Payer: Aetna Commercial |
$624.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$298.81
|
| Rate for Payer: Anthem Medicaid |
$303.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,900.00
|
| Rate for Payer: Cash Price |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,950.00
|
| Rate for Payer: Cigna Commercial |
$656.47
|
| Rate for Payer: Healthspan PPO |
$4,620.02
|
| Rate for Payer: Humana Medicaid |
$303.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$484.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$309.69
|
| Rate for Payer: Molina Healthcare Passport |
$303.62
|
| Rate for Payer: Multiplan PHCS |
$2,340.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,730.00
|
| Rate for Payer: UHCCP Medicaid |
$313.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$306.66
|
|
