|
PERQ DEV BREAST 1ST US IMAG
|
Facility
|
IP
|
$2,815.00
|
|
|
Service Code
|
HCPCS 19285
|
| Hospital Charge Code |
76100295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.95 |
| Max. Negotiated Rate |
$2,702.40 |
| Rate for Payer: Aetna Commercial |
$2,167.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,195.70
|
| Rate for Payer: Cash Price |
$1,407.50
|
| Rate for Payer: Cigna Commercial |
$2,336.45
|
| Rate for Payer: First Health Commercial |
$2,674.25
|
| Rate for Payer: Humana Commercial |
$2,392.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,308.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,077.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$844.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,477.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$563.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$872.65
|
| Rate for Payer: PHCS Commercial |
$2,702.40
|
| Rate for Payer: United Healthcare All Payer |
$2,477.20
|
|
|
PERQ DEV BREAST 1ST US IMAG(P
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 19285
|
| Hospital Charge Code |
761P0295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.42 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.42
|
| Rate for Payer: Anthem Medicaid |
$70.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$731.66
|
| Rate for Payer: Healthspan PPO |
$565.24
|
| Rate for Payer: Humana Medicaid |
$70.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.35
|
| Rate for Payer: Molina Healthcare Passport |
$70.93
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$70.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.64
|
|
|
PERQ DEV BREAST 1ST US IMAG(T
|
Facility
|
OP
|
$1,915.00
|
|
|
Service Code
|
HCPCS 19285
|
| Hospital Charge Code |
761T0295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$248.95 |
| Max. Negotiated Rate |
$1,838.40 |
| Rate for Payer: Aetna Commercial |
$1,474.55
|
| Rate for Payer: Anthem Medicaid |
$658.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,493.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$957.50
|
| Rate for Payer: Cash Price |
$957.50
|
| Rate for Payer: Cigna Commercial |
$1,589.45
|
| Rate for Payer: First Health Commercial |
$1,819.25
|
| Rate for Payer: Humana Commercial |
$1,627.75
|
| Rate for Payer: Humana KY Medicaid |
$658.57
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$665.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,570.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,413.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$671.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,685.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,436.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$383.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.65
|
| Rate for Payer: PHCS Commercial |
$1,838.40
|
| Rate for Payer: United Healthcare All Payer |
$1,685.20
|
|
|
PERQ DEV BREAST 1ST US IMAG(T
|
Facility
|
IP
|
$1,915.00
|
|
|
Service Code
|
HCPCS 19285
|
| Hospital Charge Code |
761T0295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$248.95 |
| Max. Negotiated Rate |
$1,838.40 |
| Rate for Payer: Aetna Commercial |
$1,474.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,493.70
|
| Rate for Payer: Cash Price |
$957.50
|
| Rate for Payer: Cigna Commercial |
$1,589.45
|
| Rate for Payer: First Health Commercial |
$1,819.25
|
| Rate for Payer: Humana Commercial |
$1,627.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,570.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,413.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$574.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,685.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,436.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$383.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.65
|
| Rate for Payer: PHCS Commercial |
$1,838.40
|
| Rate for Payer: United Healthcare All Payer |
$1,685.20
|
|
|
PERQ DEV BREAST ADD US IMAG
|
Facility
|
IP
|
$2,025.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
76100296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna Commercial |
$1,559.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.50
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cigna Commercial |
$1,680.75
|
| Rate for Payer: First Health Commercial |
$1,923.75
|
| Rate for Payer: Humana Commercial |
$1,721.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.75
|
| Rate for Payer: PHCS Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare All Payer |
$1,782.00
|
|
|
PERQ DEV BREAST ADD US IMAG
|
Professional
|
Both
|
$2,025.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
76100296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.94 |
| Max. Negotiated Rate |
$2,025.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.94
|
| Rate for Payer: Anthem Medicaid |
$34.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,025.00
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cigna Commercial |
$611.03
|
| Rate for Payer: Healthspan PPO |
$470.94
|
| Rate for Payer: Humana Medicaid |
$34.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.14
|
| Rate for Payer: Molina Healthcare Passport |
$34.45
|
| Rate for Payer: Multiplan PHCS |
$1,215.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,417.50
|
| Rate for Payer: UHCCP Medicaid |
$35.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.79
|
|
|
PERQ DEV BREAST ADD US IMAG
|
Facility
|
OP
|
$2,025.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
76100296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna Commercial |
$1,559.25
|
| Rate for Payer: Anthem Medicaid |
$696.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.50
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cigna Commercial |
$1,680.75
|
| Rate for Payer: First Health Commercial |
$1,923.75
|
| Rate for Payer: Humana Commercial |
$1,721.25
|
| Rate for Payer: Humana KY Medicaid |
$696.40
|
| Rate for Payer: Kentucky WC Medicaid |
$703.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.75
|
| Rate for Payer: PHCS Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare All Payer |
$1,782.00
|
|
|
PERQ DEV BREAST ADD US IMAG(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
761P0296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.94 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.94
|
| Rate for Payer: Anthem Medicaid |
$34.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$611.03
|
| Rate for Payer: Healthspan PPO |
$470.94
|
| Rate for Payer: Humana Medicaid |
$34.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.14
|
| Rate for Payer: Molina Healthcare Passport |
$34.45
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$35.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.79
|
|
|
PERQ DEV BREAST ADD US IMAG(T
|
Facility
|
OP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
761T0296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.25 |
| Max. Negotiated Rate |
$1,176.00 |
| Rate for Payer: Aetna Commercial |
$943.25
|
| Rate for Payer: Anthem Medicaid |
$421.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$955.50
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$1,016.75
|
| Rate for Payer: First Health Commercial |
$1,163.75
|
| Rate for Payer: Humana Commercial |
$1,041.25
|
| Rate for Payer: Humana KY Medicaid |
$421.28
|
| Rate for Payer: Kentucky WC Medicaid |
$425.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,004.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$904.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$429.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.75
|
| Rate for Payer: PHCS Commercial |
$1,176.00
|
| Rate for Payer: United Healthcare All Payer |
$1,078.00
|
|
|
PERQ DEV BREAST ADD US IMAG(T
|
Facility
|
IP
|
$1,225.00
|
|
|
Service Code
|
HCPCS 19286
|
| Hospital Charge Code |
761T0296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.25 |
| Max. Negotiated Rate |
$1,176.00 |
| Rate for Payer: Aetna Commercial |
$943.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$955.50
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$1,016.75
|
| Rate for Payer: First Health Commercial |
$1,163.75
|
| Rate for Payer: Humana Commercial |
$1,041.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,004.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$904.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$367.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.75
|
| Rate for Payer: PHCS Commercial |
$1,176.00
|
| Rate for Payer: United Healthcare All Payer |
$1,078.00
|
|
|
PERQ DEV SOFT TISS 1ST IMAG
|
Professional
|
Both
|
$2,008.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
76100006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.14 |
| Max. Negotiated Rate |
$2,008.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.14
|
| Rate for Payer: Anthem Medicaid |
$70.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,008.00
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna Commercial |
$144.35
|
| Rate for Payer: Humana Medicaid |
$70.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$110.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.16
|
| Rate for Payer: Molina Healthcare Passport |
$70.75
|
| Rate for Payer: Multiplan PHCS |
$1,204.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,405.60
|
| Rate for Payer: UHCCP Medicaid |
$73.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.46
|
|
|
PERQ DEV SOFT TISS 1ST IMAG
|
Facility
|
OP
|
$2,008.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
76100006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$261.04 |
| Max. Negotiated Rate |
$1,927.68 |
| Rate for Payer: Aetna Commercial |
$1,546.16
|
| Rate for Payer: Anthem Medicaid |
$690.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,566.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna Commercial |
$1,666.64
|
| Rate for Payer: First Health Commercial |
$1,907.60
|
| Rate for Payer: Humana Commercial |
$1,706.80
|
| Rate for Payer: Humana KY Medicaid |
$690.55
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$697.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,646.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,481.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$704.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,767.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$622.48
|
| Rate for Payer: PHCS Commercial |
$1,927.68
|
| Rate for Payer: United Healthcare All Payer |
$1,767.04
|
|
|
PERQ DEV SOFT TISS 1ST IMAG
|
Facility
|
IP
|
$2,008.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
76100006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$261.04 |
| Max. Negotiated Rate |
$1,927.68 |
| Rate for Payer: Aetna Commercial |
$1,546.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,566.24
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna Commercial |
$1,666.64
|
| Rate for Payer: First Health Commercial |
$1,907.60
|
| Rate for Payer: Humana Commercial |
$1,706.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,646.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,481.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$602.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,767.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$622.48
|
| Rate for Payer: PHCS Commercial |
$1,927.68
|
| Rate for Payer: United Healthcare All Payer |
$1,767.04
|
|
|
PERQ DEV SOFT TISS 1ST IMAG(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
761P0006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.14 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.14
|
| Rate for Payer: Anthem Medicaid |
$70.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$144.35
|
| Rate for Payer: Humana Medicaid |
$70.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$110.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.16
|
| Rate for Payer: Molina Healthcare Passport |
$70.75
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$73.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.46
|
|
|
PERQ DEV SOFT TISS 1ST IMAG(T
|
Facility
|
IP
|
$1,758.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
761T0006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$228.54 |
| Max. Negotiated Rate |
$1,687.68 |
| Rate for Payer: Aetna Commercial |
$1,353.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,371.24
|
| Rate for Payer: Cash Price |
$879.00
|
| Rate for Payer: Cigna Commercial |
$1,459.14
|
| Rate for Payer: First Health Commercial |
$1,670.10
|
| Rate for Payer: Humana Commercial |
$1,494.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,441.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,297.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$527.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,547.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,318.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.98
|
| Rate for Payer: PHCS Commercial |
$1,687.68
|
| Rate for Payer: United Healthcare All Payer |
$1,547.04
|
|
|
PERQ DEV SOFT TISS 1ST IMAG(T
|
Facility
|
OP
|
$1,758.00
|
|
|
Service Code
|
HCPCS 10035
|
| Hospital Charge Code |
761T0006
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$228.54 |
| Max. Negotiated Rate |
$1,687.68 |
| Rate for Payer: Aetna Commercial |
$1,353.66
|
| Rate for Payer: Anthem Medicaid |
$604.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,371.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$879.00
|
| Rate for Payer: Cash Price |
$879.00
|
| Rate for Payer: Cigna Commercial |
$1,459.14
|
| Rate for Payer: First Health Commercial |
$1,670.10
|
| Rate for Payer: Humana Commercial |
$1,494.30
|
| Rate for Payer: Humana KY Medicaid |
$604.58
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$610.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,441.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,297.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,547.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,318.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.98
|
| Rate for Payer: PHCS Commercial |
$1,687.68
|
| Rate for Payer: United Healthcare All Payer |
$1,547.04
|
|
|
PERQ&IC ALLG TEST DRUGS/BIOL
|
Professional
|
Both
|
$131.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
41000105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.66
|
| Rate for Payer: Anthem Medicaid |
$5.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$131.00
|
| Rate for Payer: Cash Price |
$65.50
|
| Rate for Payer: Cash Price |
$65.50
|
| Rate for Payer: Cigna Commercial |
$35.75
|
| Rate for Payer: Healthspan PPO |
$37.08
|
| Rate for Payer: Humana Medicaid |
$5.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$5.93
|
| Rate for Payer: Molina Healthcare Passport |
$5.81
|
| Rate for Payer: Multiplan PHCS |
$78.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$91.70
|
| Rate for Payer: UHCCP Medicaid |
$5.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.87
|
|
|
PERQ&IC ALLG TEST DRUGS/BIOL
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
41000105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$125.76 |
| Rate for Payer: Aetna Commercial |
$100.87
|
| Rate for Payer: Anthem Medicaid |
$45.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$65.50
|
| Rate for Payer: Cash Price |
$65.50
|
| Rate for Payer: Cigna Commercial |
$108.73
|
| Rate for Payer: First Health Commercial |
$124.45
|
| Rate for Payer: Humana Commercial |
$111.35
|
| Rate for Payer: Humana KY Medicaid |
$45.05
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.28
|
| Rate for Payer: Ohio Health Group HMO |
$98.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.61
|
| Rate for Payer: PHCS Commercial |
$125.76
|
| Rate for Payer: United Healthcare All Payer |
$115.28
|
|
|
PERQ&IC ALLG TEST DRUGS/BIOL
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
41000105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$125.76 |
| Rate for Payer: Aetna Commercial |
$100.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.18
|
| Rate for Payer: Cash Price |
$65.50
|
| Rate for Payer: Cigna Commercial |
$108.73
|
| Rate for Payer: First Health Commercial |
$124.45
|
| Rate for Payer: Humana Commercial |
$111.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.28
|
| Rate for Payer: Ohio Health Group HMO |
$98.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.61
|
| Rate for Payer: PHCS Commercial |
$125.76
|
| Rate for Payer: United Healthcare All Payer |
$115.28
|
|
|
PERQ&IC ALLG TEST DRUGS/BIO(P
|
Professional
|
Both
|
$57.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
410P0105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.66
|
| Rate for Payer: Anthem Medicaid |
$5.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$57.00
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$35.75
|
| Rate for Payer: Healthspan PPO |
$37.08
|
| Rate for Payer: Humana Medicaid |
$5.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$5.93
|
| Rate for Payer: Molina Healthcare Passport |
$5.81
|
| Rate for Payer: Multiplan PHCS |
$34.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.90
|
| Rate for Payer: UHCCP Medicaid |
$5.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.87
|
|
|
PERQ&IC ALLG TEST DRUGS/BIO(T
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
410T0105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
PERQ&IC ALLG TEST DRUGS/BIO(T
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
410T0105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem Medicaid |
$25.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Humana KY Medicaid |
$25.45
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$25.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
PERQ LUMBOSACRAL INJECTION
|
Facility
|
IP
|
$10,883.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
76100422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,414.79 |
| Max. Negotiated Rate |
$10,447.68 |
| Rate for Payer: Aetna Commercial |
$8,379.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,488.74
|
| Rate for Payer: Cash Price |
$5,441.50
|
| Rate for Payer: Cigna Commercial |
$9,032.89
|
| Rate for Payer: First Health Commercial |
$10,338.85
|
| Rate for Payer: Humana Commercial |
$9,250.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,924.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,031.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,264.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,577.04
|
| Rate for Payer: Ohio Health Group HMO |
$8,162.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,176.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,414.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,373.73
|
| Rate for Payer: PHCS Commercial |
$10,447.68
|
| Rate for Payer: United Healthcare All Payer |
$9,577.04
|
|
|
PERQ LUMBOSACRAL INJECTION
|
Facility
|
OP
|
$10,883.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
76100422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,414.79 |
| Max. Negotiated Rate |
$10,447.68 |
| Rate for Payer: Aetna Commercial |
$8,379.91
|
| Rate for Payer: Anthem Medicaid |
$3,742.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,488.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$5,441.50
|
| Rate for Payer: Cash Price |
$5,441.50
|
| Rate for Payer: Cigna Commercial |
$9,032.89
|
| Rate for Payer: First Health Commercial |
$10,338.85
|
| Rate for Payer: Humana Commercial |
$9,250.55
|
| Rate for Payer: Humana KY Medicaid |
$3,742.66
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,780.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,924.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,031.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,817.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,577.04
|
| Rate for Payer: Ohio Health Group HMO |
$8,162.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,176.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,414.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,373.73
|
| Rate for Payer: PHCS Commercial |
$10,447.68
|
| Rate for Payer: United Healthcare All Payer |
$9,577.04
|
|
|
PERQ LUMBOSACRAL INJECTION
|
Professional
|
Both
|
$10,883.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
76100422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.17 |
| Max. Negotiated Rate |
$10,883.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.17
|
| Rate for Payer: Anthem Medicaid |
$345.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$10,883.00
|
| Rate for Payer: Cash Price |
$5,441.50
|
| Rate for Payer: Cash Price |
$5,441.50
|
| Rate for Payer: Cigna Commercial |
$805.64
|
| Rate for Payer: Humana Medicaid |
$345.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$352.16
|
| Rate for Payer: Molina Healthcare Passport |
$345.25
|
| Rate for Payer: Multiplan PHCS |
$6,529.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7,618.10
|
| Rate for Payer: UHCCP Medicaid |
$348.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$348.70
|
|
