|
LITTLE NOSE SALINE SPRAY DROP
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
25000888
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
LITTLE NOSE SALINE SPRAY DROP
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 56184012011
|
| Hospital Charge Code |
25000888
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
LIVALO 4MG TABLET
|
Facility
|
OP
|
$27.66
|
|
|
Service Code
|
NDC 66869040490
|
| Hospital Charge Code |
25000891
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$26.55 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Anthem Medicaid |
$9.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.57
|
| Rate for Payer: Cash Price |
$13.83
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: First Health Commercial |
$26.28
|
| Rate for Payer: Humana Commercial |
$23.51
|
| Rate for Payer: Humana KY Medicaid |
$9.51
|
| Rate for Payer: Kentucky WC Medicaid |
$9.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.34
|
| Rate for Payer: Ohio Health Group HMO |
$20.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.57
|
| Rate for Payer: PHCS Commercial |
$26.55
|
| Rate for Payer: United Healthcare All Payer |
$24.34
|
|
|
LIVALO 4MG TABLET
|
Facility
|
IP
|
$27.66
|
|
|
Service Code
|
NDC 66869040490
|
| Hospital Charge Code |
25000891
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$26.55 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.57
|
| Rate for Payer: Cash Price |
$13.83
|
| Rate for Payer: Cigna Commercial |
$22.96
|
| Rate for Payer: First Health Commercial |
$26.28
|
| Rate for Payer: Humana Commercial |
$23.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.34
|
| Rate for Payer: Ohio Health Group HMO |
$20.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.57
|
| Rate for Payer: PHCS Commercial |
$26.55
|
| Rate for Payer: United Healthcare All Payer |
$24.34
|
|
|
LIVER ELASTOGRAPHY
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Anthem Medicaid |
$27.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$261.00
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$49.41
|
| Rate for Payer: Humana Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.76
|
| Rate for Payer: Molina Healthcare Passport |
$27.22
|
| Rate for Payer: Multiplan PHCS |
$156.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.70
|
| Rate for Payer: UHCCP Medicaid |
$91.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.49
|
|
|
LIVER ELASTOGRAPHY
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.58
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.91
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
LIVER ELASTOGRAPHY
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem Medicaid |
$89.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Humana KY Medicaid |
$89.76
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$90.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.91
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
LIVER ELASTOGRAPHY(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
402P0087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Anthem Medicaid |
$27.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$49.41
|
| Rate for Payer: Humana Medicaid |
$27.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.76
|
| Rate for Payer: Molina Healthcare Passport |
$27.22
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.49
|
|
|
LIVER ELASTOGRAPHY(T
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
402T0087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem Medicaid |
$72.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Humana KY Medicaid |
$72.56
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$73.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$74.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.41
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
LIVER ELASTOGRAPHY(T
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
402T0087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$202.56 |
| Rate for Payer: Aetna Commercial |
$162.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$164.58
|
| Rate for Payer: Cash Price |
$105.50
|
| Rate for Payer: Cigna Commercial |
$175.13
|
| Rate for Payer: First Health Commercial |
$200.45
|
| Rate for Payer: Humana Commercial |
$179.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$173.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$155.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$185.68
|
| Rate for Payer: Ohio Health Group HMO |
$158.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.41
|
| Rate for Payer: PHCS Commercial |
$202.56
|
| Rate for Payer: United Healthcare All Payer |
$185.68
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Facility
|
IP
|
$1,128.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$1,082.88 |
| Rate for Payer: Aetna Commercial |
$868.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$879.84
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cigna Commercial |
$936.24
|
| Rate for Payer: First Health Commercial |
$1,071.60
|
| Rate for Payer: Humana Commercial |
$958.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$924.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$832.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$992.64
|
| Rate for Payer: Ohio Health Group HMO |
$846.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.68
|
| Rate for Payer: PHCS Commercial |
$1,082.88
|
| Rate for Payer: United Healthcare All Payer |
$992.64
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Facility
|
OP
|
$1,128.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$1,082.88 |
| Rate for Payer: Aetna Commercial |
$868.56
|
| Rate for Payer: Anthem Medicaid |
$387.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$879.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cigna Commercial |
$936.24
|
| Rate for Payer: First Health Commercial |
$1,071.60
|
| Rate for Payer: Humana Commercial |
$958.80
|
| Rate for Payer: Humana KY Medicaid |
$387.92
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$391.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$924.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$832.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$395.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$992.64
|
| Rate for Payer: Ohio Health Group HMO |
$846.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.68
|
| Rate for Payer: PHCS Commercial |
$1,082.88
|
| Rate for Payer: United Healthcare All Payer |
$992.64
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Professional
|
Both
|
$1,128.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$31.54 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$210.38
|
| Rate for Payer: Anthem Medicaid |
$118.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,128.00
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cash Price |
$564.00
|
| Rate for Payer: Cigna Commercial |
$229.47
|
| Rate for Payer: Healthspan PPO |
$210.27
|
| Rate for Payer: Humana Medicaid |
$118.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.20
|
| Rate for Payer: Molina Healthcare Passport |
$118.82
|
| Rate for Payer: Multiplan PHCS |
$676.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$789.60
|
| Rate for Payer: UHCCP Medicaid |
$394.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.01
|
|
|
LIVER & SPLEEN IMAGE/FLOW(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
340P0008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$31.54 |
| Max. Negotiated Rate |
$229.47 |
| Rate for Payer: Aetna Commercial |
$210.38
|
| Rate for Payer: Anthem Medicaid |
$118.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$229.47
|
| Rate for Payer: Healthspan PPO |
$210.27
|
| Rate for Payer: Humana Medicaid |
$118.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.20
|
| Rate for Payer: Molina Healthcare Passport |
$118.82
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.01
|
|
|
LIVER & SPLEEN IMAGE/FLOW(T
|
Facility
|
OP
|
$978.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
340T0008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$938.88 |
| Rate for Payer: Aetna Commercial |
$753.06
|
| Rate for Payer: Anthem Medicaid |
$336.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$762.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$811.74
|
| Rate for Payer: First Health Commercial |
$929.10
|
| Rate for Payer: Humana Commercial |
$831.30
|
| Rate for Payer: Humana KY Medicaid |
$336.33
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$339.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$801.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$721.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$860.64
|
| Rate for Payer: Ohio Health Group HMO |
$733.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.18
|
| Rate for Payer: PHCS Commercial |
$938.88
|
| Rate for Payer: United Healthcare All Payer |
$860.64
|
|
|
LIVER & SPLEEN IMAGE/FLOW(T
|
Facility
|
IP
|
$978.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
340T0008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$938.88 |
| Rate for Payer: Aetna Commercial |
$753.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$762.84
|
| Rate for Payer: Cash Price |
$489.00
|
| Rate for Payer: Cigna Commercial |
$811.74
|
| Rate for Payer: First Health Commercial |
$929.10
|
| Rate for Payer: Humana Commercial |
$831.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$801.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$721.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$860.64
|
| Rate for Payer: Ohio Health Group HMO |
$733.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.18
|
| Rate for Payer: PHCS Commercial |
$938.88
|
| Rate for Payer: United Healthcare All Payer |
$860.64
|
|
|
LIVER & SPLEEN STATIC SCAN
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
34000007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$228.28 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.36
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
LIVER & SPLEEN STATIC SCAN
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
34000007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$228.28 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.36
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
LIVER & SPLEEN STATIC SCAN
|
Professional
|
Both
|
$1,756.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
34000007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$27.71 |
| Max. Negotiated Rate |
$1,756.00 |
| Rate for Payer: Aetna Commercial |
$273.56
|
| Rate for Payer: Anthem Medicaid |
$100.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,756.00
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$225.84
|
| Rate for Payer: Healthspan PPO |
$273.42
|
| Rate for Payer: Humana Medicaid |
$100.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.24
|
| Rate for Payer: Molina Healthcare Passport |
$100.24
|
| Rate for Payer: Multiplan PHCS |
$1,053.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,229.20
|
| Rate for Payer: UHCCP Medicaid |
$614.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.24
|
|
|
LIVER & SPLEEN STATIC SCAN(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
340P0007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$27.71 |
| Max. Negotiated Rate |
$273.56 |
| Rate for Payer: Aetna Commercial |
$273.56
|
| Rate for Payer: Anthem Medicaid |
$100.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$225.84
|
| Rate for Payer: Healthspan PPO |
$273.42
|
| Rate for Payer: Humana Medicaid |
$100.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.24
|
| Rate for Payer: Molina Healthcare Passport |
$100.24
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.24
|
|
|
LIVER & SPLEEN STATIC SCAN(T
|
Facility
|
OP
|
$1,631.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
340T0007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$212.03 |
| Max. Negotiated Rate |
$1,565.76 |
| Rate for Payer: Aetna Commercial |
$1,255.87
|
| Rate for Payer: Anthem Medicaid |
$560.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,272.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: Cigna Commercial |
$1,353.73
|
| Rate for Payer: First Health Commercial |
$1,549.45
|
| Rate for Payer: Humana Commercial |
$1,386.35
|
| Rate for Payer: Humana KY Medicaid |
$560.90
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$566.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,337.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,203.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$572.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,435.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,223.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$505.61
|
| Rate for Payer: PHCS Commercial |
$1,565.76
|
| Rate for Payer: United Healthcare All Payer |
$1,435.28
|
|
|
LIVER & SPLEEN STATIC SCAN(T
|
Facility
|
IP
|
$1,631.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
340T0007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$212.03 |
| Max. Negotiated Rate |
$1,565.76 |
| Rate for Payer: Aetna Commercial |
$1,255.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,272.18
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: Cigna Commercial |
$1,353.73
|
| Rate for Payer: First Health Commercial |
$1,549.45
|
| Rate for Payer: Humana Commercial |
$1,386.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,337.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,203.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,435.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,223.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$505.61
|
| Rate for Payer: PHCS Commercial |
$1,565.76
|
| Rate for Payer: United Healthcare All Payer |
$1,435.28
|
|
|
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$121,076.40
|
|
|
Service Code
|
MSDRG 005
|
| Min. Negotiated Rate |
$82,158.98 |
| Max. Negotiated Rate |
$121,076.40 |
| Rate for Payer: Anthem Medicaid |
$82,158.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$86,483.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$121,076.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$116,752.24
|
| Rate for Payer: Humana KY Medicaid |
$82,158.98
|
| Rate for Payer: Humana Medicare Advantage |
$86,483.14
|
| Rate for Payer: Kentucky WC Medicaid |
$82,980.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103,779.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$83,802.16
|
|
|
LIVER TRANSPLANT WITHOUT MCC
|
Facility
|
IP
|
$56,583.04
|
|
|
Service Code
|
MSDRG 006
|
| Min. Negotiated Rate |
$38,395.64 |
| Max. Negotiated Rate |
$56,583.04 |
| Rate for Payer: Anthem Medicaid |
$38,395.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40,416.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56,583.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$54,562.22
|
| Rate for Payer: Humana KY Medicaid |
$38,395.64
|
| Rate for Payer: Humana Medicare Advantage |
$40,416.46
|
| Rate for Payer: Kentucky WC Medicaid |
$38,779.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48,499.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$39,163.55
|
|
|
LIVER ULTRASOUND ONLY LTD
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200019
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$143.52 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
