|
PERFCTA TI FEM STEM SZ13.5 STD
|
Facility
|
OP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem Medicaid |
$2,971.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Humana KY Medicaid |
$2,971.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,001.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,030.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ15.0 STD
|
Facility
|
OP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem Medicaid |
$2,971.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Humana KY Medicaid |
$2,971.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,001.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,030.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ15.0 STD
|
Facility
|
IP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ16.5 STD
|
Facility
|
IP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ16.5 STD
|
Facility
|
OP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem Medicaid |
$2,971.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Humana KY Medicaid |
$2,971.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,001.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,030.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ18.0 STD
|
Facility
|
OP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem Medicaid |
$2,971.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Humana KY Medicaid |
$2,971.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3,001.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,030.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFCTA TI FEM STEM SZ18.0 STD
|
Facility
|
IP
|
$8,640.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,123.20 |
| Max. Negotiated Rate |
$8,294.40 |
| Rate for Payer: Aetna Commercial |
$6,652.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,739.20
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna Commercial |
$7,171.20
|
| Rate for Payer: First Health Commercial |
$8,208.00
|
| Rate for Payer: Humana Commercial |
$7,344.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,084.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,376.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,592.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,603.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,678.40
|
| Rate for Payer: PHCS Commercial |
$8,294.40
|
| Rate for Payer: United Healthcare All Payer |
$7,603.20
|
|
|
PERFORMER INTRO.SHEATH 12F
|
Facility
|
IP
|
$1,085.90
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$1,042.46 |
| Rate for Payer: Aetna Commercial |
$836.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$847.00
|
| Rate for Payer: Cash Price |
$542.95
|
| Rate for Payer: Cigna Commercial |
$901.30
|
| Rate for Payer: First Health Commercial |
$1,031.60
|
| Rate for Payer: Humana Commercial |
$923.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$890.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$801.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$955.59
|
| Rate for Payer: Ohio Health Group HMO |
$814.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$217.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$141.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.63
|
| Rate for Payer: PHCS Commercial |
$1,042.46
|
| Rate for Payer: United Healthcare All Payer |
$955.59
|
|
|
PERFORMER INTRO.SHEATH 12F
|
Facility
|
OP
|
$1,085.90
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$1,042.46 |
| Rate for Payer: Aetna Commercial |
$836.14
|
| Rate for Payer: Anthem Medicaid |
$373.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$847.00
|
| Rate for Payer: Cash Price |
$542.95
|
| Rate for Payer: Cigna Commercial |
$901.30
|
| Rate for Payer: First Health Commercial |
$1,031.60
|
| Rate for Payer: Humana Commercial |
$923.02
|
| Rate for Payer: Humana KY Medicaid |
$373.44
|
| Rate for Payer: Kentucky WC Medicaid |
$377.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$890.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$801.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$380.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$955.59
|
| Rate for Payer: Ohio Health Group HMO |
$814.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$217.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$141.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.63
|
| Rate for Payer: PHCS Commercial |
$1,042.46
|
| Rate for Payer: United Healthcare All Payer |
$955.59
|
|
|
PERFUSION LUNG SCAN
|
Facility
|
IP
|
$915.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
34000024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$118.95 |
| Max. Negotiated Rate |
$878.40 |
| Rate for Payer: Aetna Commercial |
$704.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$713.70
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$759.45
|
| Rate for Payer: First Health Commercial |
$869.25
|
| Rate for Payer: Humana Commercial |
$777.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$750.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$675.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$805.20
|
| Rate for Payer: Ohio Health Group HMO |
$686.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.65
|
| Rate for Payer: PHCS Commercial |
$878.40
|
| Rate for Payer: United Healthcare All Payer |
$805.20
|
|
|
PERFUSION LUNG SCAN
|
Professional
|
Both
|
$915.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
34000024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$41.05 |
| Max. Negotiated Rate |
$915.00 |
| Rate for Payer: Aetna Commercial |
$311.36
|
| Rate for Payer: Anthem Medicaid |
$124.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$915.00
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$270.39
|
| Rate for Payer: Healthspan PPO |
$311.20
|
| Rate for Payer: Humana Medicaid |
$124.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$127.36
|
| Rate for Payer: Molina Healthcare Passport |
$124.86
|
| Rate for Payer: Multiplan PHCS |
$549.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$640.50
|
| Rate for Payer: UHCCP Medicaid |
$320.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.11
|
|
|
PERFUSION LUNG SCAN
|
Facility
|
OP
|
$915.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
34000024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$118.95 |
| Max. Negotiated Rate |
$878.40 |
| Rate for Payer: Aetna Commercial |
$704.55
|
| Rate for Payer: Anthem Medicaid |
$314.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$713.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$759.45
|
| Rate for Payer: First Health Commercial |
$869.25
|
| Rate for Payer: Humana Commercial |
$777.75
|
| Rate for Payer: Humana KY Medicaid |
$314.67
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$317.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$750.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$675.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$320.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$805.20
|
| Rate for Payer: Ohio Health Group HMO |
$686.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.65
|
| Rate for Payer: PHCS Commercial |
$878.40
|
| Rate for Payer: United Healthcare All Payer |
$805.20
|
|
|
PERFUSION LUNG SCAN(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
340P0024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$41.05 |
| Max. Negotiated Rate |
$311.36 |
| Rate for Payer: Aetna Commercial |
$311.36
|
| Rate for Payer: Anthem Medicaid |
$124.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$270.39
|
| Rate for Payer: Healthspan PPO |
$311.20
|
| Rate for Payer: Humana Medicaid |
$124.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$127.36
|
| Rate for Payer: Molina Healthcare Passport |
$124.86
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.11
|
|
|
PERFUSION LUNG SCAN(T
|
Facility
|
OP
|
$765.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
340T0024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$734.40 |
| Rate for Payer: Aetna Commercial |
$589.05
|
| Rate for Payer: Anthem Medicaid |
$263.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$596.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$634.95
|
| Rate for Payer: First Health Commercial |
$726.75
|
| Rate for Payer: Humana Commercial |
$650.25
|
| Rate for Payer: Humana KY Medicaid |
$263.08
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$265.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$564.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$673.20
|
| Rate for Payer: Ohio Health Group HMO |
$573.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.15
|
| Rate for Payer: PHCS Commercial |
$734.40
|
| Rate for Payer: United Healthcare All Payer |
$673.20
|
|
|
PERFUSION LUNG SCAN(T
|
Facility
|
IP
|
$765.00
|
|
|
Service Code
|
HCPCS 78580
|
| Hospital Charge Code |
340T0024
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$99.45 |
| Max. Negotiated Rate |
$734.40 |
| Rate for Payer: Aetna Commercial |
$589.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$596.70
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$634.95
|
| Rate for Payer: First Health Commercial |
$726.75
|
| Rate for Payer: Humana Commercial |
$650.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$564.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$673.20
|
| Rate for Payer: Ohio Health Group HMO |
$573.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.15
|
| Rate for Payer: PHCS Commercial |
$734.40
|
| Rate for Payer: United Healthcare All Payer |
$673.20
|
|
|
PERIACTIN (CYPROHEPTA 4MG/1TAB
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 50742019001
|
| Hospital Charge Code |
25001175
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
PERIACTIN (CYPROHEPTA 4MG/1TAB
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 50742019001
|
| Hospital Charge Code |
25001175
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
PERIACTIN SYRUP 5ML
|
Facility
|
IP
|
$4.74
|
|
|
Service Code
|
NDC 70752010112
|
| Hospital Charge Code |
25003350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
PERIACTIN SYRUP 5ML
|
Facility
|
OP
|
$4.74
|
|
|
Service Code
|
NDC 70752010112
|
| Hospital Charge Code |
25003350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
PERICARDIAL FLUID CELL CNT
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem Medicaid |
$5.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Humana KY Medicaid |
$5.60
|
| Rate for Payer: Humana Medicare Advantage |
$5.60
|
| Rate for Payer: Kentucky WC Medicaid |
$5.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
PERICARDIAL FLUID CELL CNT
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.96 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
PERICARDIOCENTESIS TRAY 8.3FR
|
Facility
|
IP
|
$1,989.17
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
27000036
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$258.59 |
| Max. Negotiated Rate |
$1,909.60 |
| Rate for Payer: Aetna Commercial |
$1,531.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,551.55
|
| Rate for Payer: Cash Price |
$994.58
|
| Rate for Payer: Cigna Commercial |
$1,651.01
|
| Rate for Payer: First Health Commercial |
$1,889.71
|
| Rate for Payer: Humana Commercial |
$1,690.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,631.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,468.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,750.47
|
| Rate for Payer: Ohio Health Group HMO |
$1,491.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$397.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$258.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$616.64
|
| Rate for Payer: PHCS Commercial |
$1,909.60
|
| Rate for Payer: United Healthcare All Payer |
$1,750.47
|
|
|
PERICARDIOCENTESIS TRAY 8.3FR
|
Facility
|
OP
|
$1,989.17
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
27000036
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$258.59 |
| Max. Negotiated Rate |
$1,909.60 |
| Rate for Payer: Aetna Commercial |
$1,531.66
|
| Rate for Payer: Anthem Medicaid |
$684.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,551.55
|
| Rate for Payer: Cash Price |
$994.58
|
| Rate for Payer: Cigna Commercial |
$1,651.01
|
| Rate for Payer: First Health Commercial |
$1,889.71
|
| Rate for Payer: Humana Commercial |
$1,690.79
|
| Rate for Payer: Humana KY Medicaid |
$684.08
|
| Rate for Payer: Kentucky WC Medicaid |
$691.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,631.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,468.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$697.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,750.47
|
| Rate for Payer: Ohio Health Group HMO |
$1,491.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$397.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$258.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$616.64
|
| Rate for Payer: PHCS Commercial |
$1,909.60
|
| Rate for Payer: United Healthcare All Payer |
$1,750.47
|
|
|
PERICARDIOCENTESIS W/IMAGING
|
Facility
|
OP
|
$2,696.00
|
|
|
Service Code
|
HCPCS 33016
|
| Hospital Charge Code |
48100099
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$350.48 |
| Max. Negotiated Rate |
$2,588.16 |
| Rate for Payer: Aetna Commercial |
$2,075.92
|
| Rate for Payer: Anthem Medicaid |
$927.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,102.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$1,348.00
|
| Rate for Payer: Cash Price |
$1,348.00
|
| Rate for Payer: Cigna Commercial |
$2,237.68
|
| Rate for Payer: First Health Commercial |
$2,561.20
|
| Rate for Payer: Humana Commercial |
$2,291.60
|
| Rate for Payer: Humana KY Medicaid |
$927.15
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$936.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,210.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,989.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$945.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,372.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,022.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$539.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$350.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$835.76
|
| Rate for Payer: PHCS Commercial |
$2,588.16
|
| Rate for Payer: United Healthcare All Payer |
$2,372.48
|
|
|
PERICARDIOCENTESIS W/IMAGING
|
Facility
|
IP
|
$2,696.00
|
|
|
Service Code
|
HCPCS 33016
|
| Hospital Charge Code |
48100099
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$350.48 |
| Max. Negotiated Rate |
$2,588.16 |
| Rate for Payer: Aetna Commercial |
$2,075.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,102.88
|
| Rate for Payer: Cash Price |
$1,348.00
|
| Rate for Payer: Cigna Commercial |
$2,237.68
|
| Rate for Payer: First Health Commercial |
$2,561.20
|
| Rate for Payer: Humana Commercial |
$2,291.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,210.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,989.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$808.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,372.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,022.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$539.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$350.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$835.76
|
| Rate for Payer: PHCS Commercial |
$2,588.16
|
| Rate for Payer: United Healthcare All Payer |
$2,372.48
|
|
