|
MNL PREP&INSJ DP RX DLVR DEV
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 20700
|
| Hospital Charge Code |
76102822
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.75 |
| Max. Negotiated Rate |
$115.28 |
| Rate for Payer: Ambetter Exchange |
$79.39
|
| Rate for Payer: Anthem Medicaid |
$67.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.27
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Humana Medicaid |
$67.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$115.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.17
|
| Rate for Payer: Molina Healthcare Passport |
$67.81
|
| Rate for Payer: Multiplan PHCS |
$63.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.21
|
| Rate for Payer: UHCCP Medicaid |
$36.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.39
|
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Professional
|
Both
|
$170.00
|
|
|
Service Code
|
HCPCS 20704
|
| Hospital Charge Code |
76102861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$199.92 |
| Rate for Payer: Ambetter Exchange |
$142.14
|
| Rate for Payer: Anthem Medicaid |
$117.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$142.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$142.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$170.57
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Humana Medicaid |
$117.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$199.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$142.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$119.88
|
| Rate for Payer: Molina Healthcare Passport |
$117.53
|
| Rate for Payer: Multiplan PHCS |
$102.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$184.78
|
| Rate for Payer: UHCCP Medicaid |
$59.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$118.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$142.14
|
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
HCPCS 20704
|
| Hospital Charge Code |
76102861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$163.20 |
| Rate for Payer: Aetna Commercial |
$130.90
|
| Rate for Payer: Anthem Medicaid |
$58.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$132.60
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cigna Commercial |
$141.10
|
| Rate for Payer: First Health Commercial |
$161.50
|
| Rate for Payer: Humana Commercial |
$144.50
|
| Rate for Payer: Humana KY Medicaid |
$58.46
|
| Rate for Payer: Kentucky WC Medicaid |
$59.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$139.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$149.60
|
| Rate for Payer: Ohio Health Group HMO |
$127.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$117.30
|
| Rate for Payer: PHCS Commercial |
$163.20
|
| Rate for Payer: United Healthcare All Payer |
$149.60
|
|
|
MNL PREP&INSJ I-ARTIC RX DEV
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
HCPCS 20704
|
| Hospital Charge Code |
76102861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$163.20 |
| Rate for Payer: Aetna Commercial |
$130.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$132.60
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cigna Commercial |
$141.10
|
| Rate for Payer: First Health Commercial |
$161.50
|
| Rate for Payer: Humana Commercial |
$144.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$139.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$125.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$149.60
|
| Rate for Payer: Ohio Health Group HMO |
$127.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$117.30
|
| Rate for Payer: PHCS Commercial |
$163.20
|
| Rate for Payer: United Healthcare All Payer |
$149.60
|
|
|
MNL PREP&INSJ IMED RX DEV
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 20702
|
| Hospital Charge Code |
76103027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$112.82 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Ambetter Exchange |
$135.29
|
| Rate for Payer: Anthem Medicaid |
$112.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$135.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$135.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$162.35
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Humana Medicaid |
$112.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$191.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$135.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.08
|
| Rate for Payer: Molina Healthcare Passport |
$112.82
|
| Rate for Payer: Multiplan PHCS |
$204.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.88
|
| Rate for Payer: UHCCP Medicaid |
$119.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$113.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$135.29
|
|
|
MOBIC MELOXICAMO 7.5 MG CAP
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 68382005001
|
| Hospital Charge Code |
25001005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
MOBIC MELOXICAMO 7.5 MG CAP
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 68382005001
|
| Hospital Charge Code |
25001005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
MOBILE CHARGING SYSTEM 3711
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
MOBILE CHARGING SYSTEM 3711
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
MOBILIZATION OF TESTICLE
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
MOBILIZATION OF TESTICLE
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.10 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem Medicaid |
$220.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Humana KY Medicaid |
$220.10
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$222.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
MOBILIZATION OF TESTICLE
|
Professional
|
Both
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$448.00 |
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$384.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$448.00
|
| Rate for Payer: UHCCP Medicaid |
$224.00
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
761P1813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$182.93
|
| Rate for Payer: Ambetter Exchange |
$113.89
|
| Rate for Payer: Anthem Medicaid |
$103.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.67
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$173.68
|
| Rate for Payer: Healthspan PPO |
$154.26
|
| Rate for Payer: Humana Medicaid |
$103.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.45
|
| Rate for Payer: Molina Healthcare Passport |
$103.38
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.06
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.89
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.75
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$182.93
|
| Rate for Payer: Ambetter Exchange |
$113.89
|
| Rate for Payer: Anthem Medicaid |
$103.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.67
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$173.68
|
| Rate for Payer: Healthspan PPO |
$154.26
|
| Rate for Payer: Humana Medicaid |
$103.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.45
|
| Rate for Payer: Molina Healthcare Passport |
$103.38
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.06
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.89
|
|
|
MOBISYL 226.8 GM
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 225036035
|
| Hospital Charge Code |
25004138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
MOBISYL 226.8 GM
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 225036035
|
| Hospital Charge Code |
25004138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.04
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.60 |
| Max. Negotiated Rate |
$577.92 |
| Rate for Payer: Aetna Commercial |
$463.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$469.56
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cigna Commercial |
$499.66
|
| Rate for Payer: First Health Commercial |
$571.90
|
| Rate for Payer: Humana Commercial |
$511.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$493.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$444.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.76
|
| Rate for Payer: Ohio Health Group HMO |
$451.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$481.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$415.38
|
| Rate for Payer: PHCS Commercial |
$577.92
|
| Rate for Payer: United Healthcare All Payer |
$529.76
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$180.60 |
| Max. Negotiated Rate |
$577.92 |
| Rate for Payer: Aetna Commercial |
$463.54
|
| Rate for Payer: Anthem Medicaid |
$207.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$469.56
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cigna Commercial |
$499.66
|
| Rate for Payer: First Health Commercial |
$571.90
|
| Rate for Payer: Humana Commercial |
$511.70
|
| Rate for Payer: Humana KY Medicaid |
$207.03
|
| Rate for Payer: Kentucky WC Medicaid |
$209.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$493.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$444.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$211.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.76
|
| Rate for Payer: Ohio Health Group HMO |
$451.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$481.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$415.38
|
| Rate for Payer: PHCS Commercial |
$577.92
|
| Rate for Payer: United Healthcare All Payer |
$529.76
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Professional
|
Both
|
$602.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$361.20 |
| Rate for Payer: Ambetter Exchange |
$11.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$10.11
|
| Rate for Payer: Anthem Medicaid |
$38.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$11.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$11.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.74
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cash Price |
$301.00
|
| Rate for Payer: Cigna Commercial |
$70.32
|
| Rate for Payer: Humana Medicaid |
$38.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$11.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.34
|
| Rate for Payer: Molina Healthcare Passport |
$38.57
|
| Rate for Payer: Multiplan PHCS |
$361.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.88
|
| Rate for Payer: UHCCP Medicaid |
$10.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$11.45
|
|
|
MODERATE SEDATION 1ST 15 MIN(P
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370P0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Ambetter Exchange |
$11.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$10.11
|
| Rate for Payer: Anthem Medicaid |
$38.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$11.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$11.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.74
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$70.32
|
| Rate for Payer: Humana Medicaid |
$38.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$11.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.34
|
| Rate for Payer: Molina Healthcare Passport |
$38.57
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.88
|
| Rate for Payer: UHCCP Medicaid |
$10.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$11.45
|
|
|
MODERATE SEDATION 1ST 15 MIN(T
|
Facility
|
OP
|
$422.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370T0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$126.60 |
| Max. Negotiated Rate |
$405.12 |
| Rate for Payer: Aetna Commercial |
$324.94
|
| Rate for Payer: Anthem Medicaid |
$145.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.16
|
| Rate for Payer: Cash Price |
$211.00
|
| Rate for Payer: Cigna Commercial |
$350.26
|
| Rate for Payer: First Health Commercial |
$400.90
|
| Rate for Payer: Humana Commercial |
$358.70
|
| Rate for Payer: Humana KY Medicaid |
$145.13
|
| Rate for Payer: Kentucky WC Medicaid |
$146.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$311.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$148.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$371.36
|
| Rate for Payer: Ohio Health Group HMO |
$316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$367.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.18
|
| Rate for Payer: PHCS Commercial |
$405.12
|
| Rate for Payer: United Healthcare All Payer |
$371.36
|
|
|
MODERATE SEDATION 1ST 15 MIN(T
|
Facility
|
IP
|
$422.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370T0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$126.60 |
| Max. Negotiated Rate |
$405.12 |
| Rate for Payer: Aetna Commercial |
$324.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.16
|
| Rate for Payer: Cash Price |
$211.00
|
| Rate for Payer: Cigna Commercial |
$350.26
|
| Rate for Payer: First Health Commercial |
$400.90
|
| Rate for Payer: Humana Commercial |
$358.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$311.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$371.36
|
| Rate for Payer: Ohio Health Group HMO |
$316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$367.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.18
|
| Rate for Payer: PHCS Commercial |
$405.12
|
| Rate for Payer: United Healthcare All Payer |
$371.36
|
|
|
MOD HEAD 2MM HEMI HEAD 40MM
|
Facility
|
OP
|
$15,957.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,787.36 |
| Max. Negotiated Rate |
$15,319.56 |
| Rate for Payer: Aetna Commercial |
$12,287.57
|
| Rate for Payer: Anthem Medicaid |
$5,487.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,447.15
|
| Rate for Payer: Cash Price |
$7,978.94
|
| Rate for Payer: Cigna Commercial |
$13,245.04
|
| Rate for Payer: First Health Commercial |
$15,159.99
|
| Rate for Payer: Humana Commercial |
$13,564.20
|
| Rate for Payer: Humana KY Medicaid |
$5,487.91
|
| Rate for Payer: Kentucky WC Medicaid |
$5,543.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,085.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,776.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,787.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,598.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,042.93
|
| Rate for Payer: Ohio Health Group HMO |
$11,968.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,766.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,883.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,010.94
|
| Rate for Payer: PHCS Commercial |
$15,319.56
|
| Rate for Payer: United Healthcare All Payer |
$14,042.93
|
|
