|
IO MAP OF SENT LYMPH NODE
|
Professional
|
Both
|
$3,680.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.87 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$224.23
|
| Rate for Payer: Ambetter Exchange |
$130.64
|
| Rate for Payer: Anthem Medicaid |
$119.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$130.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$156.77
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Cash Price |
$1,840.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$130.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.27
|
| Rate for Payer: Molina Healthcare Passport |
$119.87
|
| Rate for Payer: Multiplan PHCS |
$2,208.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.83
|
| Rate for Payer: UHCCP Medicaid |
$1,288.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$130.64
|
|
|
IO MAP OF SENT LYMPH NODE
|
Facility
|
IP
|
$3,680.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,104.00 |
| Max. Negotiated Rate |
$3,532.80 |
| Rate for Payer: Aetna Commercial |
$2,833.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,870.40
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Cigna Commercial |
$3,054.40
|
| Rate for Payer: First Health Commercial |
$3,496.00
|
| Rate for Payer: Humana Commercial |
$3,128.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,017.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,104.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,238.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,760.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,539.20
|
| Rate for Payer: PHCS Commercial |
$3,532.80
|
| Rate for Payer: United Healthcare All Payer |
$3,238.40
|
|
|
IO MAP OF SENT LYMPH NODE
|
Facility
|
OP
|
$3,680.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
76101613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,104.00 |
| Max. Negotiated Rate |
$3,532.80 |
| Rate for Payer: Aetna Commercial |
$2,833.60
|
| Rate for Payer: Anthem Medicaid |
$1,265.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,870.40
|
| Rate for Payer: Cash Price |
$1,840.00
|
| Rate for Payer: Cigna Commercial |
$3,054.40
|
| Rate for Payer: First Health Commercial |
$3,496.00
|
| Rate for Payer: Humana Commercial |
$3,128.00
|
| Rate for Payer: Humana KY Medicaid |
$1,265.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,278.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,017.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,715.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,104.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,290.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,238.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,760.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,539.20
|
| Rate for Payer: PHCS Commercial |
$3,532.80
|
| Rate for Payer: United Healthcare All Payer |
$3,238.40
|
|
|
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: Ambetter Exchange |
$130.64
|
| Rate for Payer: Anthem Medicaid |
$119.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$130.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$156.77
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$130.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.64
|
| 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 |
$169.83
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$130.64
|
|
|
IO MAP OF SENT LYMPH NODE(T
|
Facility
|
OP
|
$3,530.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
761T1613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,059.00 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem Medicaid |
$1,213.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Humana KY Medicaid |
$1,213.97
|
| Rate for Payer: Kentucky WC Medicaid |
$1,226.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,238.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,071.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.70
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
IO MAP OF SENT LYMPH NODE(T
|
Facility
|
IP
|
$3,530.00
|
|
|
Service Code
|
HCPCS 38900
|
| Hospital Charge Code |
761T1613
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,059.00 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,071.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.70
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
IONIZED CALCIUM PROFILE
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
30000260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.83
|
| 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 |
$114.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.67
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IONIZED CALCIUM PROFILE
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS 82330
|
| Hospital Charge Code |
30000260
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem Medicaid |
$13.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$71.50
|
| 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 |
$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 |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.95
|
| 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 |
$114.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.67
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
43000009
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
42000013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
42000013
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem Medicaid |
$52.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Humana KY Medicaid |
$52.27
|
| Rate for Payer: Kentucky WC Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
IONTOPHORESIS - 15 MIN
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
43000009
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.60 |
| Max. Negotiated Rate |
$145.92 |
| Rate for Payer: Aetna Commercial |
$117.04
|
| Rate for Payer: Anthem Medicaid |
$52.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.56
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna Commercial |
$126.16
|
| Rate for Payer: First Health Commercial |
$144.40
|
| Rate for Payer: Humana Commercial |
$129.20
|
| Rate for Payer: Humana KY Medicaid |
$52.27
|
| Rate for Payer: Kentucky WC Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$133.76
|
| Rate for Payer: Ohio Health Group HMO |
$114.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.88
|
| Rate for Payer: PHCS Commercial |
$145.92
|
| Rate for Payer: United Healthcare All Payer |
$133.76
|
|
|
IOPIDINE(APRACLONIDIN)0.5%/5ML
|
Facility
|
IP
|
$2.99
|
|
|
Service Code
|
NDC 61314066505
|
| Hospital Charge Code |
25003800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| 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 |
$2.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.06
|
| 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 |
$0.90 |
| 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 |
$2.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.06
|
| 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 |
$19.72 |
| 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 |
$52.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.35
|
| 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 |
$19.72 |
| 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 |
$52.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.35
|
| Rate for Payer: PHCS Commercial |
$63.10
|
| Rate for Payer: United Healthcare All Payer |
$57.84
|
|
|
IPACK BLOCK
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102832
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| 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 |
$154.75
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| 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 |
$327.30
|
| 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 |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
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 |
$3,712.80 |
| Rate for Payer: Anthem Medicaid |
$3,640.00
|
| 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 |
$3,640.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,712.80
|
| Rate for Payer: Molina Healthcare Passport |
$3,640.00
|
| 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 |
$3,676.40
|
|
|
IPACK BLOCK
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102832
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| 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 |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| 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: 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 |
$76.25
|
| 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: 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 |
$76.25
|
| 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: 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: 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: 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: 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
|
|
