|
PERQ LUMBOSACRAL INJECTION(P
|
Professional
|
Both
|
$3,600.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
761P0422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.17 |
| Max. Negotiated Rate |
$3,600.00 |
| 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 |
$3,600.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| 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 |
$2,160.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,520.00
|
| Rate for Payer: UHCCP Medicaid |
$348.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$348.70
|
|
|
PERQ LUMBOSACRAL INJECTION(T
|
Facility
|
OP
|
$7,283.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
761T0422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$946.79 |
| Max. Negotiated Rate |
$6,991.68 |
| Rate for Payer: Aetna Commercial |
$5,607.91
|
| Rate for Payer: Anthem Medicaid |
$2,504.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,680.74
|
| 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 |
$3,641.50
|
| Rate for Payer: Cash Price |
$3,641.50
|
| Rate for Payer: Cigna Commercial |
$6,044.89
|
| Rate for Payer: First Health Commercial |
$6,918.85
|
| Rate for Payer: Humana Commercial |
$6,190.55
|
| Rate for Payer: Humana KY Medicaid |
$2,504.62
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$2,530.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,972.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,374.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,554.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,409.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,462.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,456.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,257.73
|
| Rate for Payer: PHCS Commercial |
$6,991.68
|
| Rate for Payer: United Healthcare All Payer |
$6,409.04
|
|
|
PERQ LUMBOSACRAL INJECTION(T
|
Facility
|
IP
|
$7,283.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
761T0422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$946.79 |
| Max. Negotiated Rate |
$6,991.68 |
| Rate for Payer: Aetna Commercial |
$5,607.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,680.74
|
| Rate for Payer: Cash Price |
$3,641.50
|
| Rate for Payer: Cigna Commercial |
$6,044.89
|
| Rate for Payer: First Health Commercial |
$6,918.85
|
| Rate for Payer: Humana Commercial |
$6,190.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,972.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,374.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,184.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,409.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,462.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,456.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,257.73
|
| Rate for Payer: PHCS Commercial |
$6,991.68
|
| Rate for Payer: United Healthcare All Payer |
$6,409.04
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM
|
Facility
|
OP
|
$18,165.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
76102875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,361.45 |
| Max. Negotiated Rate |
$17,438.40 |
| Rate for Payer: Aetna Commercial |
$13,987.05
|
| Rate for Payer: Anthem Medicaid |
$6,246.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,966.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,168.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,152.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,754.61
|
| Rate for Payer: Cash Price |
$9,082.50
|
| Rate for Payer: Cash Price |
$9,082.50
|
| Rate for Payer: Cigna Commercial |
$15,076.95
|
| Rate for Payer: First Health Commercial |
$17,256.75
|
| Rate for Payer: Humana Commercial |
$15,440.25
|
| Rate for Payer: Humana KY Medicaid |
$6,246.94
|
| Rate for Payer: Humana Medicare Advantage |
$7,966.38
|
| Rate for Payer: Kentucky WC Medicaid |
$6,310.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,895.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,405.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,559.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,372.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,985.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,623.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,633.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,361.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,631.15
|
| Rate for Payer: PHCS Commercial |
$17,438.40
|
| Rate for Payer: United Healthcare All Payer |
$15,985.20
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM
|
Professional
|
Both
|
$18,165.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
76102875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,040.14 |
| Max. Negotiated Rate |
$18,165.00 |
| Rate for Payer: Aetna Commercial |
$2,093.39
|
| Rate for Payer: Anthem Medicaid |
$1,040.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$18,165.00
|
| Rate for Payer: Cash Price |
$9,082.50
|
| Rate for Payer: Cash Price |
$9,082.50
|
| Rate for Payer: Cigna Commercial |
$1,859.11
|
| Rate for Payer: Healthspan PPO |
$1,673.86
|
| Rate for Payer: Humana Medicaid |
$1,040.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,745.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,060.94
|
| Rate for Payer: Molina Healthcare Passport |
$1,040.14
|
| Rate for Payer: Multiplan PHCS |
$10,899.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$12,715.50
|
| Rate for Payer: UHCCP Medicaid |
$6,357.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,050.54
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM
|
Facility
|
IP
|
$18,165.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
76102875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,361.45 |
| Max. Negotiated Rate |
$17,438.40 |
| Rate for Payer: Aetna Commercial |
$13,987.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,168.70
|
| Rate for Payer: Cash Price |
$9,082.50
|
| Rate for Payer: Cigna Commercial |
$15,076.95
|
| Rate for Payer: First Health Commercial |
$17,256.75
|
| Rate for Payer: Humana Commercial |
$15,440.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,895.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,405.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,449.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,985.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,623.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,633.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,361.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,631.15
|
| Rate for Payer: PHCS Commercial |
$17,438.40
|
| Rate for Payer: United Healthcare All Payer |
$15,985.20
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM(P
|
Professional
|
Both
|
$2,750.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
761P2875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$962.50 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Aetna Commercial |
$2,093.39
|
| Rate for Payer: Anthem Medicaid |
$1,040.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,750.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$1,859.11
|
| Rate for Payer: Healthspan PPO |
$1,673.86
|
| Rate for Payer: Humana Medicaid |
$1,040.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,745.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,060.94
|
| Rate for Payer: Molina Healthcare Passport |
$1,040.14
|
| Rate for Payer: Multiplan PHCS |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,925.00
|
| Rate for Payer: UHCCP Medicaid |
$962.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,050.54
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM(T
|
Facility
|
OP
|
$15,415.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
761T2875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,003.95 |
| Max. Negotiated Rate |
$14,798.40 |
| Rate for Payer: Aetna Commercial |
$11,869.55
|
| Rate for Payer: Anthem Medicaid |
$5,301.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,966.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,023.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,152.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,754.61
|
| Rate for Payer: Cash Price |
$7,707.50
|
| Rate for Payer: Cash Price |
$7,707.50
|
| Rate for Payer: Cigna Commercial |
$12,794.45
|
| Rate for Payer: First Health Commercial |
$14,644.25
|
| Rate for Payer: Humana Commercial |
$13,102.75
|
| Rate for Payer: Humana KY Medicaid |
$5,301.22
|
| Rate for Payer: Humana Medicare Advantage |
$7,966.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,355.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,640.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,376.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,559.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,407.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,565.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,561.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,083.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,003.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,778.65
|
| Rate for Payer: PHCS Commercial |
$14,798.40
|
| Rate for Payer: United Healthcare All Payer |
$13,565.20
|
|
|
PERQ NL/PL LITHOTRP CPLX>2CM(T
|
Facility
|
IP
|
$15,415.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
761T2875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,003.95 |
| Max. Negotiated Rate |
$14,798.40 |
| Rate for Payer: Aetna Commercial |
$11,869.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,023.70
|
| Rate for Payer: Cash Price |
$7,707.50
|
| Rate for Payer: Cigna Commercial |
$12,794.45
|
| Rate for Payer: First Health Commercial |
$14,644.25
|
| Rate for Payer: Humana Commercial |
$13,102.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,640.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,376.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,624.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,565.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,561.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,083.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,003.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,778.65
|
| Rate for Payer: PHCS Commercial |
$14,798.40
|
| Rate for Payer: United Healthcare All Payer |
$13,565.20
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM
|
Professional
|
Both
|
$16,045.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
76102874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$765.39 |
| Max. Negotiated Rate |
$16,045.00 |
| Rate for Payer: Aetna Commercial |
$1,424.28
|
| Rate for Payer: Anthem Medicaid |
$765.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$16,045.00
|
| Rate for Payer: Cash Price |
$8,022.50
|
| Rate for Payer: Cash Price |
$8,022.50
|
| Rate for Payer: Cigna Commercial |
$1,267.22
|
| Rate for Payer: Healthspan PPO |
$1,138.84
|
| Rate for Payer: Humana Medicaid |
$765.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,188.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$780.70
|
| Rate for Payer: Molina Healthcare Passport |
$765.39
|
| Rate for Payer: Multiplan PHCS |
$9,627.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11,231.50
|
| Rate for Payer: UHCCP Medicaid |
$5,615.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$773.04
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM
|
Facility
|
IP
|
$16,045.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
76102874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,085.85 |
| Max. Negotiated Rate |
$15,403.20 |
| Rate for Payer: Aetna Commercial |
$12,354.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,515.10
|
| Rate for Payer: Cash Price |
$8,022.50
|
| Rate for Payer: Cigna Commercial |
$13,317.35
|
| Rate for Payer: First Health Commercial |
$15,242.75
|
| Rate for Payer: Humana Commercial |
$13,638.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,156.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,841.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,813.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,119.60
|
| Rate for Payer: Ohio Health Group HMO |
$12,033.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,209.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,085.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,973.95
|
| Rate for Payer: PHCS Commercial |
$15,403.20
|
| Rate for Payer: United Healthcare All Payer |
$14,119.60
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM
|
Facility
|
OP
|
$16,045.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
76102874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,085.85 |
| Max. Negotiated Rate |
$15,403.20 |
| Rate for Payer: Aetna Commercial |
$12,354.65
|
| Rate for Payer: Anthem Medicaid |
$5,517.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,966.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,515.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,152.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,754.61
|
| Rate for Payer: Cash Price |
$8,022.50
|
| Rate for Payer: Cash Price |
$8,022.50
|
| Rate for Payer: Cigna Commercial |
$13,317.35
|
| Rate for Payer: First Health Commercial |
$15,242.75
|
| Rate for Payer: Humana Commercial |
$13,638.25
|
| Rate for Payer: Humana KY Medicaid |
$5,517.88
|
| Rate for Payer: Humana Medicare Advantage |
$7,966.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,574.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,156.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,841.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,559.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,628.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,119.60
|
| Rate for Payer: Ohio Health Group HMO |
$12,033.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,209.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,085.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,973.95
|
| Rate for Payer: PHCS Commercial |
$15,403.20
|
| Rate for Payer: United Healthcare All Payer |
$14,119.60
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM(P
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
761P2874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$595.00 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Aetna Commercial |
$1,424.28
|
| Rate for Payer: Anthem Medicaid |
$765.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,700.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,267.22
|
| Rate for Payer: Healthspan PPO |
$1,138.84
|
| Rate for Payer: Humana Medicaid |
$765.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,188.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$780.70
|
| Rate for Payer: Molina Healthcare Passport |
$765.39
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,190.00
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$773.04
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM(T
|
Facility
|
IP
|
$14,345.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
761T2874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,864.85 |
| Max. Negotiated Rate |
$13,771.20 |
| Rate for Payer: Aetna Commercial |
$11,045.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,189.10
|
| Rate for Payer: Cash Price |
$7,172.50
|
| Rate for Payer: Cigna Commercial |
$11,906.35
|
| Rate for Payer: First Health Commercial |
$13,627.75
|
| Rate for Payer: Humana Commercial |
$12,193.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,762.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,586.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,303.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,623.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,758.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,869.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,864.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,446.95
|
| Rate for Payer: PHCS Commercial |
$13,771.20
|
| Rate for Payer: United Healthcare All Payer |
$12,623.60
|
|
|
PERQ NL/PL LITHOTRP SMPL<2CM(T
|
Facility
|
OP
|
$14,345.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
761T2874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,864.85 |
| Max. Negotiated Rate |
$13,771.20 |
| Rate for Payer: Aetna Commercial |
$11,045.65
|
| Rate for Payer: Anthem Medicaid |
$4,933.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,966.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,189.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,152.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,754.61
|
| Rate for Payer: Cash Price |
$7,172.50
|
| Rate for Payer: Cash Price |
$7,172.50
|
| Rate for Payer: Cigna Commercial |
$11,906.35
|
| Rate for Payer: First Health Commercial |
$13,627.75
|
| Rate for Payer: Humana Commercial |
$12,193.25
|
| Rate for Payer: Humana KY Medicaid |
$4,933.25
|
| Rate for Payer: Humana Medicare Advantage |
$7,966.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,983.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,762.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,586.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,559.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,032.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,623.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,758.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,869.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,864.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,446.95
|
| Rate for Payer: PHCS Commercial |
$13,771.20
|
| Rate for Payer: United Healthcare All Payer |
$12,623.60
|
|
|
PERQ PLMT BILE DUCT STENT
|
Facility
|
OP
|
$4,210.00
|
|
|
Service Code
|
HCPCS 47539
|
| Hospital Charge Code |
76101962
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$547.30 |
| Max. Negotiated Rate |
$6,985.45 |
| Rate for Payer: Aetna Commercial |
$3,241.70
|
| Rate for Payer: Anthem Medicaid |
$1,447.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,989.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,283.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,985.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,735.97
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cigna Commercial |
$3,494.30
|
| Rate for Payer: First Health Commercial |
$3,999.50
|
| Rate for Payer: Humana Commercial |
$3,578.50
|
| Rate for Payer: Humana KY Medicaid |
$1,447.82
|
| Rate for Payer: Humana Medicare Advantage |
$4,989.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,462.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,452.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,987.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,476.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,704.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,157.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$842.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$547.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,305.10
|
| Rate for Payer: PHCS Commercial |
$4,041.60
|
| Rate for Payer: United Healthcare All Payer |
$3,704.80
|
|
|
PERQ PLMT BILE DUCT STENT
|
Professional
|
Both
|
$11,188.00
|
|
|
Service Code
|
HCPCS 47540
|
| Hospital Charge Code |
76101963
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.53 |
| Max. Negotiated Rate |
$11,188.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$432.53
|
| Rate for Payer: Anthem Medicaid |
$437.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$11,188.00
|
| Rate for Payer: Cash Price |
$5,594.00
|
| Rate for Payer: Cash Price |
$5,594.00
|
| Rate for Payer: Cigna Commercial |
$890.65
|
| Rate for Payer: Humana Medicaid |
$437.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$751.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$445.81
|
| Rate for Payer: Molina Healthcare Passport |
$437.07
|
| Rate for Payer: Multiplan PHCS |
$6,712.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7,831.60
|
| Rate for Payer: UHCCP Medicaid |
$454.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$441.44
|
|
|
PERQ PLMT BILE DUCT STENT
|
Facility
|
IP
|
$4,210.00
|
|
|
Service Code
|
HCPCS 47539
|
| Hospital Charge Code |
76101962
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$547.30 |
| Max. Negotiated Rate |
$4,041.60 |
| Rate for Payer: Aetna Commercial |
$3,241.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,283.80
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cigna Commercial |
$3,494.30
|
| Rate for Payer: First Health Commercial |
$3,999.50
|
| Rate for Payer: Humana Commercial |
$3,578.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,452.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,263.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,704.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,157.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$842.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$547.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,305.10
|
| Rate for Payer: PHCS Commercial |
$4,041.60
|
| Rate for Payer: United Healthcare All Payer |
$3,704.80
|
|
|
PERQ PLMT BILE DUCT STENT
|
Facility
|
IP
|
$11,188.00
|
|
|
Service Code
|
HCPCS 47540
|
| Hospital Charge Code |
76101963
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,454.44 |
| Max. Negotiated Rate |
$10,740.48 |
| Rate for Payer: Aetna Commercial |
$8,614.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,726.64
|
| Rate for Payer: Cash Price |
$5,594.00
|
| Rate for Payer: Cigna Commercial |
$9,286.04
|
| Rate for Payer: First Health Commercial |
$10,628.60
|
| Rate for Payer: Humana Commercial |
$9,509.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,174.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,256.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,356.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,845.44
|
| Rate for Payer: Ohio Health Group HMO |
$8,391.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,454.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,468.28
|
| Rate for Payer: PHCS Commercial |
$10,740.48
|
| Rate for Payer: United Healthcare All Payer |
$9,845.44
|
|
|
PERQ PLMT BILE DUCT STENT
|
Facility
|
OP
|
$11,188.00
|
|
|
Service Code
|
HCPCS 47540
|
| Hospital Charge Code |
76101963
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,454.44 |
| Max. Negotiated Rate |
$10,740.48 |
| Rate for Payer: Aetna Commercial |
$8,614.76
|
| Rate for Payer: Anthem Medicaid |
$3,847.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,989.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,726.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,985.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,735.97
|
| Rate for Payer: Cash Price |
$5,594.00
|
| Rate for Payer: Cash Price |
$5,594.00
|
| Rate for Payer: Cigna Commercial |
$9,286.04
|
| Rate for Payer: First Health Commercial |
$10,628.60
|
| Rate for Payer: Humana Commercial |
$9,509.80
|
| Rate for Payer: Humana KY Medicaid |
$3,847.55
|
| Rate for Payer: Humana Medicare Advantage |
$4,989.61
|
| Rate for Payer: Kentucky WC Medicaid |
$3,886.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,174.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,256.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,987.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,924.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,845.44
|
| Rate for Payer: Ohio Health Group HMO |
$8,391.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,454.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,468.28
|
| Rate for Payer: PHCS Commercial |
$10,740.48
|
| Rate for Payer: United Healthcare All Payer |
$9,845.44
|
|
|
PERQ PLMT BILE DUCT STENT
|
Professional
|
Both
|
$4,210.00
|
|
|
Service Code
|
HCPCS 47539
|
| Hospital Charge Code |
76101962
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$362.03 |
| Max. Negotiated Rate |
$4,210.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$362.03
|
| Rate for Payer: Anthem Medicaid |
$365.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,210.00
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cigna Commercial |
$746.15
|
| Rate for Payer: Humana Medicaid |
$365.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$373.17
|
| Rate for Payer: Molina Healthcare Passport |
$365.85
|
| Rate for Payer: Multiplan PHCS |
$2,526.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,947.00
|
| Rate for Payer: UHCCP Medicaid |
$380.13
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$369.51
|
|
|
PERQ PLMT BILE DUCT STENT (P
|
Professional
|
Both
|
$4,210.00
|
|
|
Service Code
|
HCPCS 47539
|
| Hospital Charge Code |
761P1962
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$362.03 |
| Max. Negotiated Rate |
$4,210.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$362.03
|
| Rate for Payer: Anthem Medicaid |
$365.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,210.00
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cash Price |
$2,105.00
|
| Rate for Payer: Cigna Commercial |
$746.15
|
| Rate for Payer: Humana Medicaid |
$365.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$373.17
|
| Rate for Payer: Molina Healthcare Passport |
$365.85
|
| Rate for Payer: Multiplan PHCS |
$2,526.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,947.00
|
| Rate for Payer: UHCCP Medicaid |
$380.13
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$369.51
|
|
|
PERQ STENT/CHEST VERT ART
|
Professional
|
Both
|
$666.40
|
|
|
Service Code
|
HCPCS 0075T
|
| Hospital Charge Code |
76102655
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$233.24 |
| Max. Negotiated Rate |
$666.40 |
| Rate for Payer: Buckeye Medicare Advantage |
$666.40
|
| Rate for Payer: Cash Price |
$333.20
|
| Rate for Payer: Multiplan PHCS |
$399.84
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$466.48
|
| Rate for Payer: UHCCP Medicaid |
$233.24
|
|
|
PERQ TRLUML CORONRY LITHOTRP
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
76102809
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
PERQ TRLUML CORONRY LITHOTRP
|
Facility
|
OP
|
$11,700.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
48100102
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,521.00 |
| Max. Negotiated Rate |
$11,232.00 |
| Rate for Payer: Aetna Commercial |
$9,009.00
|
| Rate for Payer: Anthem Medicaid |
$4,023.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,126.00
|
| Rate for Payer: Cash Price |
$5,850.00
|
| Rate for Payer: Cigna Commercial |
$9,711.00
|
| Rate for Payer: First Health Commercial |
$11,115.00
|
| Rate for Payer: Humana Commercial |
$9,945.00
|
| Rate for Payer: Humana KY Medicaid |
$4,023.63
|
| Rate for Payer: Kentucky WC Medicaid |
$4,064.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,594.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,634.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,104.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,296.00
|
| Rate for Payer: Ohio Health Group HMO |
$8,775.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,521.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,627.00
|
| Rate for Payer: PHCS Commercial |
$11,232.00
|
| Rate for Payer: United Healthcare All Payer |
$10,296.00
|
|
