|
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$3,784.94
|
|
|
Service Code
|
CPT 57410
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,703.53 |
| Max. Negotiated Rate |
$3,784.94 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| Rate for Payer: Humana Medicare Advantage |
$2,703.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.24
|
|
|
PELVIC ULTRASOUND NON OB
|
Facility
|
IP
|
$964.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
40200046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$125.32 |
| Max. Negotiated Rate |
$925.44 |
| Rate for Payer: Cash Price |
$482.00
|
| Rate for Payer: Aetna Commercial |
$742.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$751.92
|
| Rate for Payer: Cigna Commercial |
$800.12
|
| Rate for Payer: First Health Commercial |
$915.80
|
| Rate for Payer: Humana Commercial |
$819.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$790.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$711.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$289.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$848.32
|
| Rate for Payer: Ohio Health Group HMO |
$723.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.84
|
| Rate for Payer: PHCS Commercial |
$925.44
|
| Rate for Payer: United Healthcare All Payer |
$848.32
|
|
|
PELVIC ULTRASOUND NON OB
|
Facility
|
OP
|
$964.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
40200046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$925.44 |
| Rate for Payer: Aetna Commercial |
$742.28
|
| Rate for Payer: Anthem Medicaid |
$331.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$751.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$482.00
|
| Rate for Payer: Cash Price |
$482.00
|
| Rate for Payer: Cigna Commercial |
$800.12
|
| Rate for Payer: First Health Commercial |
$915.80
|
| Rate for Payer: Humana Commercial |
$819.40
|
| Rate for Payer: Humana KY Medicaid |
$331.52
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$334.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$790.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$711.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$338.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$848.32
|
| Rate for Payer: Ohio Health Group HMO |
$723.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.84
|
| Rate for Payer: PHCS Commercial |
$925.44
|
| Rate for Payer: United Healthcare All Payer |
$848.32
|
|
|
PELVIC ULTRASOUND NON OB
|
Professional
|
Both
|
$964.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
40200046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$964.00 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$964.00
|
| Rate for Payer: Cash Price |
$482.00
|
| Rate for Payer: Cash Price |
$482.00
|
| Rate for Payer: Cigna Commercial |
$155.61
|
| Rate for Payer: Healthspan PPO |
$171.87
|
| Rate for Payer: Humana Medicaid |
$71.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.80
|
| Rate for Payer: Molina Healthcare Passport |
$71.37
|
| Rate for Payer: Multiplan PHCS |
$578.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$674.80
|
| Rate for Payer: UHCCP Medicaid |
$337.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
|
|
PELVIC ULTRASOUND NON OB(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
402P0046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$183.42 |
| Rate for Payer: Aetna Commercial |
$183.42
|
| Rate for Payer: Anthem Medicaid |
$71.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$155.61
|
| Rate for Payer: Healthspan PPO |
$171.87
|
| Rate for Payer: Humana Medicaid |
$71.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.80
|
| Rate for Payer: Molina Healthcare Passport |
$71.37
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.08
|
|
|
PELVIC ULTRASOUND NON OB(T
|
Facility
|
IP
|
$839.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
402T0046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$109.07 |
| Max. Negotiated Rate |
$805.44 |
| Rate for Payer: Aetna Commercial |
$646.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$654.42
|
| Rate for Payer: Cash Price |
$419.50
|
| Rate for Payer: Cigna Commercial |
$696.37
|
| Rate for Payer: First Health Commercial |
$797.05
|
| Rate for Payer: Humana Commercial |
$713.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$619.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$738.32
|
| Rate for Payer: Ohio Health Group HMO |
$629.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.09
|
| Rate for Payer: PHCS Commercial |
$805.44
|
| Rate for Payer: United Healthcare All Payer |
$738.32
|
|
|
PELVIC ULTRASOUND NON OB(T
|
Facility
|
OP
|
$839.00
|
|
|
Service Code
|
HCPCS 76856
|
| Hospital Charge Code |
402T0046
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$805.44 |
| Rate for Payer: Aetna Commercial |
$646.03
|
| Rate for Payer: Anthem Medicaid |
$288.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$654.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$419.50
|
| Rate for Payer: Cash Price |
$419.50
|
| Rate for Payer: Cigna Commercial |
$696.37
|
| Rate for Payer: First Health Commercial |
$797.05
|
| Rate for Payer: Humana Commercial |
$713.15
|
| Rate for Payer: Humana KY Medicaid |
$288.53
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$291.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$619.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$294.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$738.32
|
| Rate for Payer: Ohio Health Group HMO |
$629.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.09
|
| Rate for Payer: PHCS Commercial |
$805.44
|
| Rate for Payer: United Healthcare All Payer |
$738.32
|
|
|
PELVIS 1-2 VWS
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
61000023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$335.00 |
| Rate for Payer: Aetna Commercial |
$39.25
|
| Rate for Payer: Anthem Medicaid |
$21.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$335.00
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$41.44
|
| Rate for Payer: Healthspan PPO |
$36.78
|
| Rate for Payer: Humana Medicaid |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.68
|
| Rate for Payer: Molina Healthcare Passport |
$21.25
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.50
|
| Rate for Payer: UHCCP Medicaid |
$117.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.46
|
|
|
PELVIS 1-2 VWS
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
61000023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem Medicaid |
$115.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Humana KY Medicaid |
$115.21
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$116.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
PELVIS 1-2 VWS
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
61000023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
PELVIS 1-2 VWS(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
610P0023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$41.44 |
| Rate for Payer: Aetna Commercial |
$39.25
|
| Rate for Payer: Anthem Medicaid |
$21.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$41.44
|
| Rate for Payer: Healthspan PPO |
$36.78
|
| Rate for Payer: Humana Medicaid |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.68
|
| Rate for Payer: Molina Healthcare Passport |
$21.25
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.46
|
|
|
PELVIS 1-2 VWS(T
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
610T0023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem Medicaid |
$101.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Humana KY Medicaid |
$101.45
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
PELVIS 1-2 VWS(T
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
HCPCS 72170
|
| Hospital Charge Code |
610T0023
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$91.45
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
PEN-GK 600KU(from20MMU MDV)
|
Facility
|
OP
|
$8.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
25004242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: Anthem Medicaid |
$2.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.51
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: First Health Commercial |
$7.92
|
| Rate for Payer: Humana Commercial |
$7.09
|
| Rate for Payer: Humana KY Medicaid |
$2.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.34
|
| Rate for Payer: Ohio Health Group HMO |
$6.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.59
|
| Rate for Payer: PHCS Commercial |
$8.01
|
| Rate for Payer: United Healthcare All Payer |
$7.34
|
|
|
PEN-GK 600KU(from20MMU MDV)
|
Facility
|
IP
|
$8.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
25004242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.51
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: First Health Commercial |
$7.92
|
| Rate for Payer: Humana Commercial |
$7.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.34
|
| Rate for Payer: Ohio Health Group HMO |
$6.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.59
|
| Rate for Payer: PHCS Commercial |
$8.01
|
| Rate for Payer: United Healthcare All Payer |
$7.34
|
|
|
PEN-GK 600KU(FROM20MMU MDV)AIC
|
Facility
|
IP
|
$8.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
25004243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.51
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: First Health Commercial |
$7.92
|
| Rate for Payer: Humana Commercial |
$7.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.34
|
| Rate for Payer: Ohio Health Group HMO |
$6.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.59
|
| Rate for Payer: PHCS Commercial |
$8.01
|
| Rate for Payer: United Healthcare All Payer |
$7.34
|
|
|
PEN-GK 600KU(FROM20MMU MDV)AIC
|
Facility
|
OP
|
$8.34
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
25004243
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$8.01 |
| Rate for Payer: Aetna Commercial |
$6.42
|
| Rate for Payer: Anthem Medicaid |
$2.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.51
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: First Health Commercial |
$7.92
|
| Rate for Payer: Humana Commercial |
$7.09
|
| Rate for Payer: Humana KY Medicaid |
$2.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.34
|
| Rate for Payer: Ohio Health Group HMO |
$6.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.59
|
| Rate for Payer: PHCS Commercial |
$8.01
|
| Rate for Payer: United Healthcare All Payer |
$7.34
|
|
|
PENICILLIUM NOTATUM IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000706
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
PENICILLIUM NOTATUM IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000706
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
PENILE INJECTION
|
Professional
|
Both
|
$913.81
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
76102134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.84 |
| Max. Negotiated Rate |
$913.81 |
| Rate for Payer: Aetna Commercial |
$119.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.84
|
| Rate for Payer: Anthem Medicaid |
$41.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$913.81
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cigna Commercial |
$126.71
|
| Rate for Payer: Healthspan PPO |
$139.92
|
| Rate for Payer: Humana Medicaid |
$41.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$42.49
|
| Rate for Payer: Molina Healthcare Passport |
$41.66
|
| Rate for Payer: Multiplan PHCS |
$548.29
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$639.67
|
| Rate for Payer: UHCCP Medicaid |
$38.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.08
|
|
|
PENILE INJECTION
|
Facility
|
OP
|
$913.81
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
76102134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.80 |
| Max. Negotiated Rate |
$877.26 |
| Rate for Payer: Aetna Commercial |
$703.63
|
| Rate for Payer: Anthem Medicaid |
$314.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$712.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cigna Commercial |
$758.46
|
| Rate for Payer: First Health Commercial |
$868.12
|
| Rate for Payer: Humana Commercial |
$776.74
|
| Rate for Payer: Humana KY Medicaid |
$314.26
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$317.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$749.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$674.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$320.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$804.15
|
| Rate for Payer: Ohio Health Group HMO |
$685.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$182.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.28
|
| Rate for Payer: PHCS Commercial |
$877.26
|
| Rate for Payer: United Healthcare All Payer |
$804.15
|
|
|
PENILE INJECTION
|
Facility
|
IP
|
$913.81
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
76102134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.80 |
| Max. Negotiated Rate |
$877.26 |
| Rate for Payer: Aetna Commercial |
$703.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$712.77
|
| Rate for Payer: Cash Price |
$456.90
|
| Rate for Payer: Cigna Commercial |
$758.46
|
| Rate for Payer: First Health Commercial |
$868.12
|
| Rate for Payer: Humana Commercial |
$776.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$749.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$674.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$804.15
|
| Rate for Payer: Ohio Health Group HMO |
$685.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$182.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.28
|
| Rate for Payer: PHCS Commercial |
$877.26
|
| Rate for Payer: United Healthcare All Payer |
$804.15
|
|
|
PENILE INJECTION(P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
761P2134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.84 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna Commercial |
$119.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.84
|
| Rate for Payer: Anthem Medicaid |
$41.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.00
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$126.71
|
| Rate for Payer: Healthspan PPO |
$139.92
|
| Rate for Payer: Humana Medicaid |
$41.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$42.49
|
| Rate for Payer: Molina Healthcare Passport |
$41.66
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.50
|
| Rate for Payer: UHCCP Medicaid |
$38.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.08
|
|
|
PENILE INJECTION(T
|
Facility
|
OP
|
$438.81
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
761T2134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.05 |
| Max. Negotiated Rate |
$421.26 |
| Rate for Payer: Aetna Commercial |
$337.88
|
| Rate for Payer: Anthem Medicaid |
$150.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$342.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$219.40
|
| Rate for Payer: Cash Price |
$219.40
|
| Rate for Payer: Cigna Commercial |
$364.21
|
| Rate for Payer: First Health Commercial |
$416.87
|
| Rate for Payer: Humana Commercial |
$372.99
|
| Rate for Payer: Humana KY Medicaid |
$150.91
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$152.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$359.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$323.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$153.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$386.15
|
| Rate for Payer: Ohio Health Group HMO |
$329.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$87.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.03
|
| Rate for Payer: PHCS Commercial |
$421.26
|
| Rate for Payer: United Healthcare All Payer |
$386.15
|
|
|
PENILE INJECTION(T
|
Facility
|
IP
|
$438.81
|
|
|
Service Code
|
HCPCS 54235
|
| Hospital Charge Code |
761T2134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.05 |
| Max. Negotiated Rate |
$421.26 |
| Rate for Payer: Aetna Commercial |
$337.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$342.27
|
| Rate for Payer: Cash Price |
$219.40
|
| Rate for Payer: Cigna Commercial |
$364.21
|
| Rate for Payer: First Health Commercial |
$416.87
|
| Rate for Payer: Humana Commercial |
$372.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$359.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$323.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$131.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$386.15
|
| Rate for Payer: Ohio Health Group HMO |
$329.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$87.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.03
|
| Rate for Payer: PHCS Commercial |
$421.26
|
| Rate for Payer: United Healthcare All Payer |
$386.15
|
|
