|
MAGNUM 2 KNOTLESS IMPLANT
|
Facility
|
OP
|
$3,193.51
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$958.05 |
| Max. Negotiated Rate |
$3,065.77 |
| Rate for Payer: Aetna Commercial |
$2,459.00
|
| Rate for Payer: Anthem Medicaid |
$1,098.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,490.94
|
| Rate for Payer: Cash Price |
$1,596.76
|
| Rate for Payer: Cigna Commercial |
$2,650.61
|
| Rate for Payer: First Health Commercial |
$3,033.83
|
| Rate for Payer: Humana Commercial |
$2,714.48
|
| Rate for Payer: Humana KY Medicaid |
$1,098.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,109.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,618.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,356.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$958.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,120.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,810.29
|
| Rate for Payer: Ohio Health Group HMO |
$2,395.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,554.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,778.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,203.52
|
| Rate for Payer: PHCS Commercial |
$3,065.77
|
| Rate for Payer: United Healthcare All Payer |
$2,810.29
|
|
|
MAGNUM 2 KNOTLESS IMPLANT
|
Facility
|
IP
|
$3,193.51
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$958.05 |
| Max. Negotiated Rate |
$3,065.77 |
| Rate for Payer: Aetna Commercial |
$2,459.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,490.94
|
| Rate for Payer: Cash Price |
$1,596.76
|
| Rate for Payer: Cigna Commercial |
$2,650.61
|
| Rate for Payer: First Health Commercial |
$3,033.83
|
| Rate for Payer: Humana Commercial |
$2,714.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,618.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,356.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$958.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,810.29
|
| Rate for Payer: Ohio Health Group HMO |
$2,395.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,554.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,778.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,203.52
|
| Rate for Payer: PHCS Commercial |
$3,065.77
|
| Rate for Payer: United Healthcare All Payer |
$2,810.29
|
|
|
MAG-OX (MAGNESIUM O 400MG/1TAB
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 603020922
|
| Hospital Charge Code |
25000940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
MAG-OX (MAGNESIUM O 400MG/1TAB
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 603020922
|
| Hospital Charge Code |
25000940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.92
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
MAGSEED 18G 12CM PART# 052511
|
Facility
|
OP
|
$2,308.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
27000265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.40 |
| Max. Negotiated Rate |
$2,215.68 |
| Rate for Payer: Aetna Commercial |
$1,777.16
|
| Rate for Payer: Anthem Medicaid |
$793.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,800.24
|
| Rate for Payer: Cash Price |
$1,154.00
|
| Rate for Payer: Cigna Commercial |
$1,915.64
|
| Rate for Payer: First Health Commercial |
$2,192.60
|
| Rate for Payer: Humana Commercial |
$1,961.80
|
| Rate for Payer: Humana KY Medicaid |
$793.72
|
| Rate for Payer: Kentucky WC Medicaid |
$801.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,892.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,703.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$692.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$809.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,031.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,592.52
|
| Rate for Payer: PHCS Commercial |
$2,215.68
|
| Rate for Payer: United Healthcare All Payer |
$2,031.04
|
|
|
MAGSEED 18G 12CM PART# 052511
|
Facility
|
IP
|
$2,308.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
27000265
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.40 |
| Max. Negotiated Rate |
$2,215.68 |
| Rate for Payer: Aetna Commercial |
$1,777.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,800.24
|
| Rate for Payer: Cash Price |
$1,154.00
|
| Rate for Payer: Cigna Commercial |
$1,915.64
|
| Rate for Payer: First Health Commercial |
$2,192.60
|
| Rate for Payer: Humana Commercial |
$1,961.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,892.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,703.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$692.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,031.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,592.52
|
| Rate for Payer: PHCS Commercial |
$2,215.68
|
| Rate for Payer: United Healthcare All Payer |
$2,031.04
|
|
|
MAGSEED 18GM 7CM PART# 052617
|
Facility
|
OP
|
$2,308.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
27000264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.40 |
| Max. Negotiated Rate |
$2,215.68 |
| Rate for Payer: Aetna Commercial |
$1,777.16
|
| Rate for Payer: Anthem Medicaid |
$793.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,800.24
|
| Rate for Payer: Cash Price |
$1,154.00
|
| Rate for Payer: Cigna Commercial |
$1,915.64
|
| Rate for Payer: First Health Commercial |
$2,192.60
|
| Rate for Payer: Humana Commercial |
$1,961.80
|
| Rate for Payer: Humana KY Medicaid |
$793.72
|
| Rate for Payer: Kentucky WC Medicaid |
$801.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,892.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,703.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$692.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$809.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,031.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,592.52
|
| Rate for Payer: PHCS Commercial |
$2,215.68
|
| Rate for Payer: United Healthcare All Payer |
$2,031.04
|
|
|
MAGSEED 18GM 7CM PART# 052617
|
Facility
|
IP
|
$2,308.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
27000264
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.40 |
| Max. Negotiated Rate |
$2,215.68 |
| Rate for Payer: Aetna Commercial |
$1,777.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,800.24
|
| Rate for Payer: Cash Price |
$1,154.00
|
| Rate for Payer: Cigna Commercial |
$1,915.64
|
| Rate for Payer: First Health Commercial |
$2,192.60
|
| Rate for Payer: Humana Commercial |
$1,961.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,892.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,703.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$692.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,031.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,592.52
|
| Rate for Payer: PHCS Commercial |
$2,215.68
|
| Rate for Payer: United Healthcare All Payer |
$2,031.04
|
|
|
MAG-TAB (MAGNESIUM L 84MG/1TAB
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
NDC 59016042019
|
| Hospital Charge Code |
25000941
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MAG-TAB (MAGNESIUM L 84MG/1TAB
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
NDC 59016042019
|
| Hospital Charge Code |
25000941
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
MAHURKAR 12 X 16 TRIPLE LUMEN
|
Facility
|
OP
|
$3,216.12
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
27000041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$964.84 |
| Max. Negotiated Rate |
$3,087.48 |
| Rate for Payer: Aetna Commercial |
$2,476.41
|
| Rate for Payer: Anthem Medicaid |
$1,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,508.57
|
| Rate for Payer: Cash Price |
$1,608.06
|
| Rate for Payer: Cigna Commercial |
$2,669.38
|
| Rate for Payer: First Health Commercial |
$3,055.31
|
| Rate for Payer: Humana Commercial |
$2,733.70
|
| Rate for Payer: Humana KY Medicaid |
$1,106.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,117.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,637.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,373.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,128.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,830.19
|
| Rate for Payer: Ohio Health Group HMO |
$2,412.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,572.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,798.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,219.12
|
| Rate for Payer: PHCS Commercial |
$3,087.48
|
| Rate for Payer: United Healthcare All Payer |
$2,830.19
|
|
|
MAHURKAR 12 X 16 TRIPLE LUMEN
|
Facility
|
IP
|
$3,216.12
|
|
|
Service Code
|
HCPCS C1752
|
| Hospital Charge Code |
27000041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$964.84 |
| Max. Negotiated Rate |
$3,087.48 |
| Rate for Payer: Aetna Commercial |
$2,476.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,508.57
|
| Rate for Payer: Cash Price |
$1,608.06
|
| Rate for Payer: Cigna Commercial |
$2,669.38
|
| Rate for Payer: First Health Commercial |
$3,055.31
|
| Rate for Payer: Humana Commercial |
$2,733.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,637.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,373.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,830.19
|
| Rate for Payer: Ohio Health Group HMO |
$2,412.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,572.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,798.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,219.12
|
| Rate for Payer: PHCS Commercial |
$3,087.48
|
| Rate for Payer: United Healthcare All Payer |
$2,830.19
|
|
|
MAILMAN 182CM
|
Facility
|
IP
|
$1,168.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.55 |
| Max. Negotiated Rate |
$1,121.76 |
| Rate for Payer: Aetna Commercial |
$899.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$911.43
|
| Rate for Payer: Cash Price |
$584.25
|
| Rate for Payer: Cigna Commercial |
$969.86
|
| Rate for Payer: First Health Commercial |
$1,110.08
|
| Rate for Payer: Humana Commercial |
$993.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$958.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$862.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,028.28
|
| Rate for Payer: Ohio Health Group HMO |
$876.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$934.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.26
|
| Rate for Payer: PHCS Commercial |
$1,121.76
|
| Rate for Payer: United Healthcare All Payer |
$1,028.28
|
|
|
MAILMAN 182CM
|
Facility
|
OP
|
$1,168.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.55 |
| Max. Negotiated Rate |
$1,121.76 |
| Rate for Payer: Aetna Commercial |
$899.75
|
| Rate for Payer: Anthem Medicaid |
$401.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$911.43
|
| Rate for Payer: Cash Price |
$584.25
|
| Rate for Payer: Cigna Commercial |
$969.86
|
| Rate for Payer: First Health Commercial |
$1,110.08
|
| Rate for Payer: Humana Commercial |
$993.23
|
| Rate for Payer: Humana KY Medicaid |
$401.85
|
| Rate for Payer: Kentucky WC Medicaid |
$405.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$958.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$862.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$409.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,028.28
|
| Rate for Payer: Ohio Health Group HMO |
$876.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$934.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.26
|
| Rate for Payer: PHCS Commercial |
$1,121.76
|
| Rate for Payer: United Healthcare All Payer |
$1,028.28
|
|
|
MAINT OF WAKEFULNESS (MWT)
|
Professional
|
Both
|
$1,514.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$73.98 |
| Max. Negotiated Rate |
$959.14 |
| Rate for Payer: Aetna Commercial |
$641.16
|
| Rate for Payer: Ambetter Exchange |
$391.92
|
| Rate for Payer: Anthem Medicaid |
$213.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$470.30
|
| Rate for Payer: Cash Price |
$757.00
|
| Rate for Payer: Cash Price |
$757.00
|
| Rate for Payer: Cigna Commercial |
$959.14
|
| Rate for Payer: Healthspan PPO |
$560.73
|
| Rate for Payer: Humana Medicaid |
$213.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.17
|
| Rate for Payer: Molina Healthcare Passport |
$213.89
|
| Rate for Payer: Multiplan PHCS |
$908.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.50
|
| Rate for Payer: UHCCP Medicaid |
$529.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.92
|
|
|
MAINT OF WAKEFULNESS (MWT)
|
Facility
|
OP
|
$1,514.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$490.26 |
| Max. Negotiated Rate |
$1,453.44 |
| Rate for Payer: Aetna Commercial |
$1,165.78
|
| Rate for Payer: Anthem Medicaid |
$520.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,180.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$757.00
|
| Rate for Payer: Cash Price |
$757.00
|
| Rate for Payer: Cigna Commercial |
$1,256.62
|
| Rate for Payer: First Health Commercial |
$1,438.30
|
| Rate for Payer: Humana Commercial |
$1,286.90
|
| Rate for Payer: Humana KY Medicaid |
$520.66
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$525.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,241.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,117.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$531.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,332.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,135.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,317.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.66
|
| Rate for Payer: PHCS Commercial |
$1,453.44
|
| Rate for Payer: United Healthcare All Payer |
$1,332.32
|
|
|
MAINT OF WAKEFULNESS (MWT)
|
Facility
|
IP
|
$1,514.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$454.20 |
| Max. Negotiated Rate |
$1,453.44 |
| Rate for Payer: Aetna Commercial |
$1,165.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,180.92
|
| Rate for Payer: Cash Price |
$757.00
|
| Rate for Payer: Cigna Commercial |
$1,256.62
|
| Rate for Payer: First Health Commercial |
$1,438.30
|
| Rate for Payer: Humana Commercial |
$1,286.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,241.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,117.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$454.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,332.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,135.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,317.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.66
|
| Rate for Payer: PHCS Commercial |
$1,453.44
|
| Rate for Payer: United Healthcare All Payer |
$1,332.32
|
|
|
MAINT OF WAKEFULNESS (MWT)(P
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740P0001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$959.14 |
| Rate for Payer: Aetna Commercial |
$641.16
|
| Rate for Payer: Ambetter Exchange |
$391.92
|
| Rate for Payer: Anthem Medicaid |
$213.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$470.30
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$959.14
|
| Rate for Payer: Healthspan PPO |
$560.73
|
| Rate for Payer: Humana Medicaid |
$213.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.17
|
| Rate for Payer: Molina Healthcare Passport |
$213.89
|
| Rate for Payer: Multiplan PHCS |
$111.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.50
|
| Rate for Payer: UHCCP Medicaid |
$64.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.92
|
|
|
MAINT OF WAKEFULNESS (MWT)(T
|
Facility
|
IP
|
$1,329.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740T0001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$398.70 |
| Max. Negotiated Rate |
$1,275.84 |
| Rate for Payer: Aetna Commercial |
$1,023.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,036.62
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cigna Commercial |
$1,103.07
|
| Rate for Payer: First Health Commercial |
$1,262.55
|
| Rate for Payer: Humana Commercial |
$1,129.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,089.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$980.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$398.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,169.52
|
| Rate for Payer: Ohio Health Group HMO |
$996.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,063.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,156.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$917.01
|
| Rate for Payer: PHCS Commercial |
$1,275.84
|
| Rate for Payer: United Healthcare All Payer |
$1,169.52
|
|
|
MAINT OF WAKEFULNESS (MWT)(T
|
Facility
|
OP
|
$1,329.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740T0001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$457.04 |
| Max. Negotiated Rate |
$1,275.84 |
| Rate for Payer: Aetna Commercial |
$1,023.33
|
| Rate for Payer: Anthem Medicaid |
$457.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,036.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cash Price |
$664.50
|
| Rate for Payer: Cigna Commercial |
$1,103.07
|
| Rate for Payer: First Health Commercial |
$1,262.55
|
| Rate for Payer: Humana Commercial |
$1,129.65
|
| Rate for Payer: Humana KY Medicaid |
$457.04
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$461.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,089.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$980.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$466.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,169.52
|
| Rate for Payer: Ohio Health Group HMO |
$996.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,063.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,156.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$917.01
|
| Rate for Payer: PHCS Commercial |
$1,275.84
|
| Rate for Payer: United Healthcare All Payer |
$1,169.52
|
|
|
Malaria SMEAR
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
30001330
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
Malaria SMEAR
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
30001330
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem Medicaid |
$5.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.99
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Humana KY Medicaid |
$5.99
|
| Rate for Payer: Humana Medicare Advantage |
$5.99
|
| Rate for Payer: Kentucky WC Medicaid |
$6.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
MAMMO BREAST SPEC-1 VW (SURG)
|
Facility
|
IP
|
$770.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
32000184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$231.00 |
| Max. Negotiated Rate |
$739.20 |
| Rate for Payer: Aetna Commercial |
$592.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$600.60
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$639.10
|
| Rate for Payer: First Health Commercial |
$731.50
|
| Rate for Payer: Humana Commercial |
$654.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$631.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$568.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$231.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$677.60
|
| Rate for Payer: Ohio Health Group HMO |
$577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$669.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$531.30
|
| Rate for Payer: PHCS Commercial |
$739.20
|
| Rate for Payer: United Healthcare All Payer |
$677.60
|
|
|
MAMMO BREAST SPEC-1 VW (SURG)
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
32000184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$462.00 |
| Rate for Payer: Aetna Commercial |
$30.64
|
| Rate for Payer: Ambetter Exchange |
$39.02
|
| Rate for Payer: Anthem Medicaid |
$18.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$33.67
|
| Rate for Payer: Healthspan PPO |
$28.71
|
| Rate for Payer: Humana Medicaid |
$18.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.64
|
| Rate for Payer: Molina Healthcare Passport |
$18.27
|
| Rate for Payer: Multiplan PHCS |
$462.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.73
|
| Rate for Payer: UHCCP Medicaid |
$269.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.02
|
|
|
MAMMO BREAST SPEC-1 VW (SURG)
|
Facility
|
OP
|
$770.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
32000184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$264.80 |
| Max. Negotiated Rate |
$739.20 |
| Rate for Payer: Aetna Commercial |
$592.90
|
| Rate for Payer: Anthem Medicaid |
$264.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$506.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$600.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$709.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$683.94
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cash Price |
$385.00
|
| Rate for Payer: Cigna Commercial |
$639.10
|
| Rate for Payer: First Health Commercial |
$731.50
|
| Rate for Payer: Humana Commercial |
$654.50
|
| Rate for Payer: Humana KY Medicaid |
$264.80
|
| Rate for Payer: Humana Medicare Advantage |
$506.62
|
| Rate for Payer: Kentucky WC Medicaid |
$267.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$631.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$568.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$270.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$677.60
|
| Rate for Payer: Ohio Health Group HMO |
$577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$669.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$531.30
|
| Rate for Payer: PHCS Commercial |
$739.20
|
| Rate for Payer: United Healthcare All Payer |
$677.60
|
|
