|
LITHOTRIPSY, SHOCK WAVE
|
Facility
|
IP
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
76102053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,470.00 |
| Max. Negotiated Rate |
$4,704.00 |
| Rate for Payer: Aetna Commercial |
$3,773.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$4,067.00
|
| Rate for Payer: First Health Commercial |
$4,655.00
|
| Rate for Payer: Humana Commercial |
$4,165.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,018.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,616.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,312.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,263.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,381.00
|
| Rate for Payer: PHCS Commercial |
$4,704.00
|
| Rate for Payer: United Healthcare All Payer |
$4,312.00
|
|
|
LITHOTRIPSY, SHOCK WAVE(P
|
Professional
|
Both
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
761P2053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$348.52 |
| Max. Negotiated Rate |
$2,940.00 |
| Rate for Payer: Aetna Commercial |
$915.91
|
| Rate for Payer: Ambetter Exchange |
$541.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$348.52
|
| Rate for Payer: Anthem Medicaid |
$577.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$541.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$541.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$649.27
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$805.13
|
| Rate for Payer: Healthspan PPO |
$1,165.88
|
| Rate for Payer: Humana Medicaid |
$577.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$768.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$541.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.56
|
| Rate for Payer: Molina Healthcare Passport |
$577.02
|
| Rate for Payer: Multiplan PHCS |
$2,940.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$703.38
|
| Rate for Payer: UHCCP Medicaid |
$365.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$541.06
|
|
|
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 |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
LIVALO 4MG TABLET
|
Facility
|
IP
|
$27.66
|
|
|
Service Code
|
NDC 66869040490
|
| Hospital Charge Code |
25000891
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.30 |
| 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 |
$20.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.09
|
| Rate for Payer: PHCS Commercial |
$26.55
|
| Rate for Payer: United Healthcare All Payer |
$24.34
|
|
|
LIVALO 4MG TABLET
|
Facility
|
OP
|
$27.66
|
|
|
Service Code
|
NDC 66869040490
|
| Hospital Charge Code |
25000891
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.30 |
| 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 |
$20.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.09
|
| Rate for Payer: PHCS Commercial |
$26.55
|
| Rate for Payer: United Healthcare All Payer |
$24.34
|
|
|
LIVER ELASTOGRAPHY
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$92.17 |
| Max. Negotiated Rate |
$257.28 |
| Rate for Payer: Aetna Commercial |
$206.36
|
| Rate for Payer: Anthem Medicaid |
$92.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cigna Commercial |
$222.44
|
| Rate for Payer: First Health Commercial |
$254.60
|
| Rate for Payer: Humana Commercial |
$227.80
|
| Rate for Payer: Humana KY Medicaid |
$92.17
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$93.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$219.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.84
|
| Rate for Payer: Ohio Health Group HMO |
$201.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$214.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.92
|
| Rate for Payer: PHCS Commercial |
$257.28
|
| Rate for Payer: United Healthcare All Payer |
$235.84
|
|
|
LIVER ELASTOGRAPHY
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$18.32 |
| Max. Negotiated Rate |
$160.80 |
| Rate for Payer: Ambetter Exchange |
$27.50
|
| Rate for Payer: Anthem Medicaid |
$27.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$27.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$27.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.00
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cash Price |
$134.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$27.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.76
|
| Rate for Payer: Molina Healthcare Passport |
$27.22
|
| Rate for Payer: Multiplan PHCS |
$160.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.75
|
| Rate for Payer: UHCCP Medicaid |
$93.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$27.50
|
|
|
LIVER ELASTOGRAPHY
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
40200087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$80.40 |
| Max. Negotiated Rate |
$257.28 |
| Rate for Payer: Aetna Commercial |
$206.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.04
|
| Rate for Payer: Cash Price |
$134.00
|
| Rate for Payer: Cigna Commercial |
$222.44
|
| Rate for Payer: First Health Commercial |
$254.60
|
| Rate for Payer: Humana Commercial |
$227.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$219.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.84
|
| Rate for Payer: Ohio Health Group HMO |
$201.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$214.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.92
|
| Rate for Payer: PHCS Commercial |
$257.28
|
| Rate for Payer: United Healthcare All Payer |
$235.84
|
|
|
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 |
$49.41 |
| Rate for Payer: Ambetter Exchange |
$27.50
|
| Rate for Payer: Anthem Medicaid |
$27.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$27.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$27.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$27.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.50
|
| 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 |
$35.75
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$27.50
|
|
|
LIVER ELASTOGRAPHY(T
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
402T0087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem Medicaid |
$74.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Humana KY Medicaid |
$74.97
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$75.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$76.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$189.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.42
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
LIVER ELASTOGRAPHY(T
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS 91200
|
| Hospital Charge Code |
402T0087
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$65.40 |
| Max. Negotiated Rate |
$209.28 |
| Rate for Payer: Aetna Commercial |
$167.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$170.04
|
| Rate for Payer: Cash Price |
$109.00
|
| Rate for Payer: Cigna Commercial |
$180.94
|
| Rate for Payer: First Health Commercial |
$207.10
|
| Rate for Payer: Humana Commercial |
$185.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$178.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$160.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$191.84
|
| Rate for Payer: Ohio Health Group HMO |
$163.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$174.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$189.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.42
|
| Rate for Payer: PHCS Commercial |
$209.28
|
| Rate for Payer: United Healthcare All Payer |
$191.84
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Facility
|
OP
|
$1,162.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,115.52 |
| Rate for Payer: Aetna Commercial |
$894.74
|
| Rate for Payer: Anthem Medicaid |
$399.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$581.00
|
| Rate for Payer: Cash Price |
$581.00
|
| Rate for Payer: Cigna Commercial |
$964.46
|
| Rate for Payer: First Health Commercial |
$1,103.90
|
| Rate for Payer: Humana Commercial |
$987.70
|
| Rate for Payer: Humana KY Medicaid |
$399.61
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$403.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$407.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.56
|
| Rate for Payer: Ohio Health Group HMO |
$871.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$929.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$801.78
|
| Rate for Payer: PHCS Commercial |
$1,115.52
|
| Rate for Payer: United Healthcare All Payer |
$1,022.56
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Facility
|
IP
|
$1,162.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$348.60 |
| Max. Negotiated Rate |
$1,115.52 |
| Rate for Payer: Aetna Commercial |
$894.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.36
|
| Rate for Payer: Cash Price |
$581.00
|
| Rate for Payer: Cigna Commercial |
$964.46
|
| Rate for Payer: First Health Commercial |
$1,103.90
|
| Rate for Payer: Humana Commercial |
$987.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.56
|
| Rate for Payer: Ohio Health Group HMO |
$871.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$929.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$801.78
|
| Rate for Payer: PHCS Commercial |
$1,115.52
|
| Rate for Payer: United Healthcare All Payer |
$1,022.56
|
|
|
LIVER & SPLEEN IMAGE/FLOW
|
Professional
|
Both
|
$1,162.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
34000008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$31.54 |
| Max. Negotiated Rate |
$697.20 |
| Rate for Payer: Aetna Commercial |
$210.38
|
| Rate for Payer: Ambetter Exchange |
$121.85
|
| Rate for Payer: Anthem Medicaid |
$118.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$121.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$121.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$146.22
|
| Rate for Payer: Cash Price |
$581.00
|
| Rate for Payer: Cash Price |
$581.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$121.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.20
|
| Rate for Payer: Molina Healthcare Passport |
$118.82
|
| Rate for Payer: Multiplan PHCS |
$697.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$158.41
|
| Rate for Payer: UHCCP Medicaid |
$406.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$121.85
|
|
|
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: Ambetter Exchange |
$121.85
|
| Rate for Payer: Anthem Medicaid |
$118.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$121.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$121.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$146.22
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$121.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.85
|
| 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 |
$158.41
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$121.85
|
|
|
LIVER & SPLEEN IMAGE/FLOW(T
|
Facility
|
IP
|
$1,012.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
340T0008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$303.60 |
| Max. Negotiated Rate |
$971.52 |
| Rate for Payer: Aetna Commercial |
$779.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$789.36
|
| Rate for Payer: Cash Price |
$506.00
|
| Rate for Payer: Cigna Commercial |
$839.96
|
| Rate for Payer: First Health Commercial |
$961.40
|
| Rate for Payer: Humana Commercial |
$860.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$829.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$746.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$303.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$890.56
|
| Rate for Payer: Ohio Health Group HMO |
$759.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$809.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$880.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$698.28
|
| Rate for Payer: PHCS Commercial |
$971.52
|
| Rate for Payer: United Healthcare All Payer |
$890.56
|
|
|
LIVER & SPLEEN IMAGE/FLOW(T
|
Facility
|
OP
|
$1,012.00
|
|
|
Service Code
|
HCPCS 78216
|
| Hospital Charge Code |
340T0008
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$348.03 |
| Max. Negotiated Rate |
$971.52 |
| Rate for Payer: Aetna Commercial |
$779.24
|
| Rate for Payer: Anthem Medicaid |
$348.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$789.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$506.00
|
| Rate for Payer: Cash Price |
$506.00
|
| Rate for Payer: Cigna Commercial |
$839.96
|
| Rate for Payer: First Health Commercial |
$961.40
|
| Rate for Payer: Humana Commercial |
$860.20
|
| Rate for Payer: Humana KY Medicaid |
$348.03
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$351.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$829.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$746.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$355.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$890.56
|
| Rate for Payer: Ohio Health Group HMO |
$759.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$809.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$880.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$698.28
|
| Rate for Payer: PHCS Commercial |
$971.52
|
| Rate for Payer: United Healthcare All Payer |
$890.56
|
|
|
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 |
$1,053.60 |
| Rate for Payer: Aetna Commercial |
$273.56
|
| Rate for Payer: Ambetter Exchange |
$160.48
|
| Rate for Payer: Anthem Medicaid |
$100.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$160.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$192.58
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$160.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.48
|
| 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 |
$208.62
|
| Rate for Payer: UHCCP Medicaid |
$614.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$160.48
|
|
|
LIVER & SPLEEN STATIC SCAN
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS 78215
|
| Hospital Charge Code |
34000007
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| 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 |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| 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 |
$371.28
|
| 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 |
$445.54
|
| 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 |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| 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 |
$526.80 |
| 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 |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
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: Ambetter Exchange |
$160.48
|
| Rate for Payer: Anthem Medicaid |
$100.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$160.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$192.58
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$160.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.48
|
| 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 |
$208.62
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$160.48
|
|
|
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 |
$489.30 |
| 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 |
$1,304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,418.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,125.39
|
| Rate for Payer: PHCS Commercial |
$1,565.76
|
| Rate for Payer: United Healthcare All Payer |
$1,435.28
|
|
|
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 |
$371.28 |
| 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 |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,272.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| 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 |
$371.28
|
| 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 |
$445.54
|
| 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 |
$1,304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,418.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,125.39
|
| Rate for Payer: PHCS Commercial |
$1,565.76
|
| Rate for Payer: United Healthcare All Payer |
$1,435.28
|
|
|
LIVER ULTRASOUND ONLY LTD
|
Facility
|
IP
|
$1,167.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200019
|
|
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
|
|
