|
APP CLUFT CAS WMOLDIMAN LNGSHT
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 29450
|
| Hospital Charge Code |
76101063
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.03 |
| Max. Negotiated Rate |
$204.11 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem Medicaid |
$66.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Humana KY Medicaid |
$66.03
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
APP CLUFT CAS WMOLDIMAN LNGSHT
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS 29450
|
| Hospital Charge Code |
76101063
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
APPENDECTOMY
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
76101869
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.24 |
| Max. Negotiated Rate |
$8,071.56 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,765.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,071.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,783.29
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$5,765.40
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,918.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
APPENDECTOMY
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
76101869
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
APPENDECTOMY
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
76101869
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$443.78 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$927.50
|
| Rate for Payer: Ambetter Exchange |
$612.92
|
| Rate for Payer: Anthem Medicaid |
$443.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$612.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$612.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$735.50
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$867.13
|
| Rate for Payer: Healthspan PPO |
$782.18
|
| Rate for Payer: Humana Medicaid |
$443.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$818.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$612.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$612.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$452.66
|
| Rate for Payer: Molina Healthcare Passport |
$443.78
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$796.80
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$448.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$612.92
|
|
|
APPENDECTOMY; FOR RUPTURED APP
|
Professional
|
Both
|
$1,450.00
|
|
|
Service Code
|
HCPCS 44960
|
| Hospital Charge Code |
761P1871
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$475.09 |
| Max. Negotiated Rate |
$1,244.88 |
| Rate for Payer: Aetna Commercial |
$1,244.88
|
| Rate for Payer: Ambetter Exchange |
$836.84
|
| Rate for Payer: Anthem Medicaid |
$475.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$836.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$836.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,004.21
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,151.91
|
| Rate for Payer: Healthspan PPO |
$1,049.83
|
| Rate for Payer: Humana Medicaid |
$475.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,113.09
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$836.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$836.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$484.59
|
| Rate for Payer: Molina Healthcare Passport |
$475.09
|
| Rate for Payer: Multiplan PHCS |
$870.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,087.89
|
| Rate for Payer: UHCCP Medicaid |
$507.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$479.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$836.84
|
|
|
APPENDECTOMY; FOR RUPTURED APP
|
Facility
|
IP
|
$1,450.00
|
|
|
Service Code
|
HCPCS 44960
|
| Hospital Charge Code |
76101871
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,392.00 |
| Rate for Payer: Aetna Commercial |
$1,116.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,131.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,203.50
|
| Rate for Payer: First Health Commercial |
$1,377.50
|
| Rate for Payer: Humana Commercial |
$1,232.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,189.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,070.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$435.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,276.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,261.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,000.50
|
| Rate for Payer: PHCS Commercial |
$1,392.00
|
| Rate for Payer: United Healthcare All Payer |
$1,276.00
|
|
|
APPENDECTOMY; FOR RUPTURED APP
|
Facility
|
OP
|
$1,450.00
|
|
|
Service Code
|
HCPCS 44960
|
| Hospital Charge Code |
76101871
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,392.00 |
| Rate for Payer: Aetna Commercial |
$1,116.50
|
| Rate for Payer: Anthem Medicaid |
$498.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,131.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,203.50
|
| Rate for Payer: First Health Commercial |
$1,377.50
|
| Rate for Payer: Humana Commercial |
$1,232.50
|
| Rate for Payer: Humana KY Medicaid |
$498.65
|
| Rate for Payer: Kentucky WC Medicaid |
$503.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,189.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,070.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$435.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$508.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,276.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,261.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,000.50
|
| Rate for Payer: PHCS Commercial |
$1,392.00
|
| Rate for Payer: United Healthcare All Payer |
$1,276.00
|
|
|
APPENDECTOMY; FOR RUPTURED APP
|
Professional
|
Both
|
$1,450.00
|
|
|
Service Code
|
HCPCS 44960
|
| Hospital Charge Code |
76101871
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$475.09 |
| Max. Negotiated Rate |
$1,244.88 |
| Rate for Payer: Aetna Commercial |
$1,244.88
|
| Rate for Payer: Ambetter Exchange |
$836.84
|
| Rate for Payer: Anthem Medicaid |
$475.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$836.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$836.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,004.21
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,151.91
|
| Rate for Payer: Healthspan PPO |
$1,049.83
|
| Rate for Payer: Humana Medicaid |
$475.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,113.09
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$836.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$836.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$484.59
|
| Rate for Payer: Molina Healthcare Passport |
$475.09
|
| Rate for Payer: Multiplan PHCS |
$870.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,087.89
|
| Rate for Payer: UHCCP Medicaid |
$507.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$479.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$836.84
|
|
|
APPENDECTOMY(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44950
|
| Hospital Charge Code |
761P1869
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$443.78 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$927.50
|
| Rate for Payer: Ambetter Exchange |
$612.92
|
| Rate for Payer: Anthem Medicaid |
$443.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$612.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$612.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$735.50
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$867.13
|
| Rate for Payer: Healthspan PPO |
$782.18
|
| Rate for Payer: Humana Medicaid |
$443.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$818.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$612.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$612.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$452.66
|
| Rate for Payer: Molina Healthcare Passport |
$443.78
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$796.80
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$448.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$612.92
|
|
|
APPENDECTOMY; WHEN DONE FOR IN
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
HCPCS 44955
|
| Hospital Charge Code |
76101870
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem Medicaid |
$189.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Humana KY Medicaid |
$189.15
|
| Rate for Payer: Kentucky WC Medicaid |
$191.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
APPENDECTOMY; WHEN DONE FOR IN
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
HCPCS 44955
|
| Hospital Charge Code |
76101870
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
APPENDECTOMY; WHEN DONE FOR IN
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 44955
|
| Hospital Charge Code |
761P1870
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.12 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna Commercial |
$127.19
|
| Rate for Payer: Ambetter Exchange |
$79.12
|
| Rate for Payer: Anthem Medicaid |
$112.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.94
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$120.93
|
| Rate for Payer: Healthspan PPO |
$107.26
|
| Rate for Payer: Humana Medicaid |
$112.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$108.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$114.29
|
| Rate for Payer: Molina Healthcare Passport |
$112.05
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.86
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$113.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.12
|
|
|
APPENDECTOMY; WHEN DONE FOR IN
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 44955
|
| Hospital Charge Code |
76101870
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.12 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna Commercial |
$127.19
|
| Rate for Payer: Ambetter Exchange |
$79.12
|
| Rate for Payer: Anthem Medicaid |
$112.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.94
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$120.93
|
| Rate for Payer: Healthspan PPO |
$107.26
|
| Rate for Payer: Humana Medicaid |
$112.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$108.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$114.29
|
| Rate for Payer: Molina Healthcare Passport |
$112.05
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.86
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$113.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.12
|
|
|
APPENDIX ULTRASOUND LTD
|
Facility
|
IP
|
$1,167.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$350.10 |
| Max. Negotiated Rate |
$1,120.32 |
| Rate for Payer: Aetna Commercial |
$898.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$910.26
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cigna Commercial |
$968.61
|
| Rate for Payer: First Health Commercial |
$1,108.65
|
| Rate for Payer: Humana Commercial |
$991.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.96
|
| Rate for Payer: Ohio Health Group HMO |
$875.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,015.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$805.23
|
| Rate for Payer: PHCS Commercial |
$1,120.32
|
| Rate for Payer: United Healthcare All Payer |
$1,026.96
|
|
|
APPENDIX ULTRASOUND LTD
|
Professional
|
Both
|
$1,167.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$700.20 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Ambetter Exchange |
$78.47
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.16
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$700.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.01
|
| Rate for Payer: UHCCP Medicaid |
$408.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.47
|
|
|
APPENDIX ULTRASOUND LTD
|
Facility
|
OP
|
$1,167.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$1,120.32 |
| Rate for Payer: Aetna Commercial |
$898.59
|
| Rate for Payer: Anthem Medicaid |
$401.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$910.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cigna Commercial |
$968.61
|
| Rate for Payer: First Health Commercial |
$1,108.65
|
| Rate for Payer: Humana Commercial |
$991.95
|
| Rate for Payer: Humana KY Medicaid |
$401.33
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$405.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$409.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.96
|
| Rate for Payer: Ohio Health Group HMO |
$875.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,015.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$805.23
|
| Rate for Payer: PHCS Commercial |
$1,120.32
|
| Rate for Payer: United Healthcare All Payer |
$1,026.96
|
|
|
APPENDIX ULTRASOUND LTD(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Ambetter Exchange |
$78.47
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.16
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.01
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.47
|
|
|
APPENDIX ULTRASOUND LTD(T
|
Facility
|
IP
|
$1,042.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$312.60 |
| Max. Negotiated Rate |
$1,000.32 |
| Rate for Payer: Aetna Commercial |
$802.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$812.76
|
| Rate for Payer: Cash Price |
$521.00
|
| Rate for Payer: Cigna Commercial |
$864.86
|
| Rate for Payer: First Health Commercial |
$989.90
|
| Rate for Payer: Humana Commercial |
$885.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$854.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$769.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$916.96
|
| Rate for Payer: Ohio Health Group HMO |
$781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$833.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$906.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$718.98
|
| Rate for Payer: PHCS Commercial |
$1,000.32
|
| Rate for Payer: United Healthcare All Payer |
$916.96
|
|
|
APPENDIX ULTRASOUND LTD(T
|
Facility
|
OP
|
$1,042.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$1,000.32 |
| Rate for Payer: Aetna Commercial |
$802.34
|
| Rate for Payer: Anthem Medicaid |
$358.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$812.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$521.00
|
| Rate for Payer: Cash Price |
$521.00
|
| Rate for Payer: Cigna Commercial |
$864.86
|
| Rate for Payer: First Health Commercial |
$989.90
|
| Rate for Payer: Humana Commercial |
$885.70
|
| Rate for Payer: Humana KY Medicaid |
$358.34
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$361.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$854.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$769.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$365.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$916.96
|
| Rate for Payer: Ohio Health Group HMO |
$781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$833.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$906.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$718.98
|
| Rate for Payer: PHCS Commercial |
$1,000.32
|
| Rate for Payer: United Healthcare All Payer |
$916.96
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
45000191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$51.24 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem Medicaid |
$51.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$116.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Humana KY Medicaid |
$51.24
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$51.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.81
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
45000191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$44.70 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$116.22
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.81
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
76101054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem Medicaid |
$46.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Humana KY Medicaid |
$46.08
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$46.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.46
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
76101054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.20 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.52
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.46
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
45000190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
