|
LT BREAST LUMP US (P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402P0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$141.32 |
| Rate for Payer: Ambetter Exchange |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.40
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$141.32
|
| Rate for Payer: Humana Medicaid |
$67.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.99
|
| Rate for Payer: Molina Healthcare Passport |
$67.64
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.10
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.00
|
|
|
LT BREAST LUMP US(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402P0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$141.32 |
| Rate for Payer: Ambetter Exchange |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.40
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$141.32
|
| Rate for Payer: Humana Medicaid |
$67.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.99
|
| Rate for Payer: Molina Healthcare Passport |
$67.64
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.10
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.00
|
|
|
LT BREAST LUMP US (T
|
Facility
|
IP
|
$758.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.40 |
| Max. Negotiated Rate |
$727.68 |
| Rate for Payer: Aetna Commercial |
$583.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$591.24
|
| Rate for Payer: Cash Price |
$379.00
|
| Rate for Payer: Cigna Commercial |
$629.14
|
| Rate for Payer: First Health Commercial |
$720.10
|
| Rate for Payer: Humana Commercial |
$644.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$667.04
|
| Rate for Payer: Ohio Health Group HMO |
$568.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$606.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.02
|
| Rate for Payer: PHCS Commercial |
$727.68
|
| Rate for Payer: United Healthcare All Payer |
$667.04
|
|
|
LT BREAST LUMP US (T
|
Facility
|
OP
|
$758.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$727.68 |
| Rate for Payer: Aetna Commercial |
$583.66
|
| Rate for Payer: Anthem Medicaid |
$260.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$591.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$379.00
|
| Rate for Payer: Cash Price |
$379.00
|
| Rate for Payer: Cigna Commercial |
$629.14
|
| Rate for Payer: First Health Commercial |
$720.10
|
| Rate for Payer: Humana Commercial |
$644.30
|
| Rate for Payer: Humana KY Medicaid |
$260.68
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$263.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$621.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$559.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$265.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$667.04
|
| Rate for Payer: Ohio Health Group HMO |
$568.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$606.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$523.02
|
| Rate for Payer: PHCS Commercial |
$727.68
|
| Rate for Payer: United Healthcare All Payer |
$667.04
|
|
|
LT BREAST LUMP US(T
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem Medicaid |
$269.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Humana KY Medicaid |
$269.96
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$272.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$541.65
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
LT BREAST LUMP US(T
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.50 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$541.65
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
LT BREAST US
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$791.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.90
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
|
LT BREAST US
|
Professional
|
Both
|
$910.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$46.90 |
| Max. Negotiated Rate |
$546.00 |
| Rate for Payer: Ambetter Exchange |
$92.47
|
| Rate for Payer: Anthem Medicaid |
$81.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$92.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$92.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.96
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$171.21
|
| Rate for Payer: Humana Medicaid |
$81.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$92.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$83.44
|
| Rate for Payer: Molina Healthcare Passport |
$81.80
|
| Rate for Payer: Multiplan PHCS |
$546.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$120.21
|
| Rate for Payer: UHCCP Medicaid |
$318.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$92.47
|
|
|
LT BREAST US
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem Medicaid |
$312.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Humana KY Medicaid |
$312.95
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$316.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$319.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$791.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.90
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
|
LT BREAST US(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402P0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$171.21 |
| Rate for Payer: Ambetter Exchange |
$92.47
|
| Rate for Payer: Anthem Medicaid |
$81.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$92.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$92.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.96
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$171.21
|
| Rate for Payer: Humana Medicaid |
$81.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$92.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$83.44
|
| Rate for Payer: Molina Healthcare Passport |
$81.80
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$120.21
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$92.47
|
|
|
LT BREAST US(T
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402T0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem Medicaid |
$269.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Humana KY Medicaid |
$269.96
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$272.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$541.65
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
LT BREAST US(T
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402T0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$235.50 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$541.65
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
LUBRIDERM SEN SKIN 16 OZ
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 52800048856
|
| Hospital Charge Code |
25000922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem Medicaid |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Humana KY Medicaid |
$0.09
|
| Rate for Payer: Kentucky WC Medicaid |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.18
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
LUBRIDERM SEN SKIN 16 OZ
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 52800048856
|
| Hospital Charge Code |
25000922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.18
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
LUMASON 25 MG/5 ML VIAL
|
Facility
|
OP
|
$650.73
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
25003953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$195.22 |
| Max. Negotiated Rate |
$624.70 |
| Rate for Payer: Aetna Commercial |
$501.06
|
| Rate for Payer: Anthem Medicaid |
$223.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.57
|
| Rate for Payer: Cash Price |
$325.36
|
| Rate for Payer: Cigna Commercial |
$540.11
|
| Rate for Payer: First Health Commercial |
$618.19
|
| Rate for Payer: Humana Commercial |
$553.12
|
| Rate for Payer: Humana KY Medicaid |
$223.79
|
| Rate for Payer: Kentucky WC Medicaid |
$226.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$480.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.64
|
| Rate for Payer: Ohio Health Group HMO |
$488.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$566.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$449.00
|
| Rate for Payer: PHCS Commercial |
$624.70
|
| Rate for Payer: United Healthcare All Payer |
$572.64
|
|
|
LUMASON 25 MG/5 ML VIAL
|
Facility
|
IP
|
$650.73
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
25003953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$195.22 |
| Max. Negotiated Rate |
$624.70 |
| Rate for Payer: Aetna Commercial |
$501.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.57
|
| Rate for Payer: Cash Price |
$325.36
|
| Rate for Payer: Cigna Commercial |
$540.11
|
| Rate for Payer: First Health Commercial |
$618.19
|
| Rate for Payer: Humana Commercial |
$553.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$480.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.64
|
| Rate for Payer: Ohio Health Group HMO |
$488.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$566.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$449.00
|
| Rate for Payer: PHCS Commercial |
$624.70
|
| Rate for Payer: United Healthcare All Payer |
$572.64
|
|
|
LUMBAR PUNCTURE
|
Facility
|
OP
|
$1,034.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
36001260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$355.59 |
| Max. Negotiated Rate |
$992.64 |
| Rate for Payer: Aetna Commercial |
$796.18
|
| Rate for Payer: Anthem Medicaid |
$355.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$806.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$517.00
|
| Rate for Payer: Cash Price |
$517.00
|
| Rate for Payer: Cigna Commercial |
$858.22
|
| Rate for Payer: First Health Commercial |
$982.30
|
| Rate for Payer: Humana Commercial |
$878.90
|
| Rate for Payer: Humana KY Medicaid |
$355.59
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$359.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$847.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$362.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$909.92
|
| Rate for Payer: Ohio Health Group HMO |
$775.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$827.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.46
|
| Rate for Payer: PHCS Commercial |
$992.64
|
| Rate for Payer: United Healthcare All Payer |
$909.92
|
|
|
LUMBAR PUNCTURE
|
Facility
|
IP
|
$1,034.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
36001260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$310.20 |
| Max. Negotiated Rate |
$992.64 |
| Rate for Payer: Aetna Commercial |
$796.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$806.52
|
| Rate for Payer: Cash Price |
$517.00
|
| Rate for Payer: Cigna Commercial |
$858.22
|
| Rate for Payer: First Health Commercial |
$982.30
|
| Rate for Payer: Humana Commercial |
$878.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$847.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$763.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$909.92
|
| Rate for Payer: Ohio Health Group HMO |
$775.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$827.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.46
|
| Rate for Payer: PHCS Commercial |
$992.64
|
| Rate for Payer: United Healthcare All Payer |
$909.92
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
OP
|
$1,045.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
45000293
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$359.38 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem Medicaid |
$359.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Humana KY Medicaid |
$359.38
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$363.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.05
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
|
LUMBAR PUNCTURE DIAG
|
Professional
|
Both
|
$1,295.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
76102291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$777.00 |
| Rate for Payer: Aetna Commercial |
$125.69
|
| Rate for Payer: Ambetter Exchange |
$61.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.49
|
| Rate for Payer: Anthem Medicaid |
$106.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.79
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cigna Commercial |
$112.15
|
| Rate for Payer: Healthspan PPO |
$185.69
|
| Rate for Payer: Humana Medicaid |
$106.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$61.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.89
|
| Rate for Payer: Molina Healthcare Passport |
$106.75
|
| Rate for Payer: Multiplan PHCS |
$777.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.94
|
| Rate for Payer: UHCCP Medicaid |
$33.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.49
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
IP
|
$1,295.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
76102291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.50 |
| Max. Negotiated Rate |
$1,243.20 |
| Rate for Payer: Aetna Commercial |
$997.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,010.10
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cigna Commercial |
$1,074.85
|
| Rate for Payer: First Health Commercial |
$1,230.25
|
| Rate for Payer: Humana Commercial |
$1,100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,061.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$955.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$388.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,139.60
|
| Rate for Payer: Ohio Health Group HMO |
$971.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,036.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,126.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$893.55
|
| Rate for Payer: PHCS Commercial |
$1,243.20
|
| Rate for Payer: United Healthcare All Payer |
$1,139.60
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
IP
|
$1,045.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
45000293
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$313.50 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.05
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
OP
|
$1,295.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
76102291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.35 |
| Max. Negotiated Rate |
$1,243.20 |
| Rate for Payer: Aetna Commercial |
$997.15
|
| Rate for Payer: Anthem Medicaid |
$445.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,010.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cigna Commercial |
$1,074.85
|
| Rate for Payer: First Health Commercial |
$1,230.25
|
| Rate for Payer: Humana Commercial |
$1,100.75
|
| Rate for Payer: Humana KY Medicaid |
$445.35
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$449.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,061.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$955.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$454.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,139.60
|
| Rate for Payer: Ohio Health Group HMO |
$971.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,036.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,126.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$893.55
|
| Rate for Payer: PHCS Commercial |
$1,243.20
|
| Rate for Payer: United Healthcare All Payer |
$1,139.60
|
|
|
LUMBAR PUNCTURE DIAG(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
761P2291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$185.69 |
| Rate for Payer: Aetna Commercial |
$125.69
|
| Rate for Payer: Ambetter Exchange |
$61.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.49
|
| Rate for Payer: Anthem Medicaid |
$106.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.79
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$112.15
|
| Rate for Payer: Healthspan PPO |
$185.69
|
| Rate for Payer: Humana Medicaid |
$106.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$61.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.89
|
| Rate for Payer: Molina Healthcare Passport |
$106.75
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.94
|
| Rate for Payer: UHCCP Medicaid |
$33.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.49
|
|
|
LUMBAR PUNCTURE DIAG(T
|
Facility
|
OP
|
$1,045.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
761T2291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$359.38 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem Medicaid |
$359.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Humana KY Medicaid |
$359.38
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$363.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.05
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
