|
PLACE DUOD/JEJ TUBE PERC(T
|
Facility
|
IP
|
$2,961.24
|
|
|
Service Code
|
HCPCS 49441
|
| Hospital Charge Code |
761T2005
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.96 |
| Max. Negotiated Rate |
$2,842.79 |
| Rate for Payer: Aetna Commercial |
$2,280.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,309.77
|
| Rate for Payer: Cash Price |
$1,480.62
|
| Rate for Payer: Cigna Commercial |
$2,457.83
|
| Rate for Payer: First Health Commercial |
$2,813.18
|
| Rate for Payer: Humana Commercial |
$2,517.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,428.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,185.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$888.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,605.89
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$592.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$917.98
|
| Rate for Payer: PHCS Commercial |
$2,842.79
|
| Rate for Payer: United Healthcare All Payer |
$2,605.89
|
|
|
PLACE DUOD/JEJ TUBE PERC(T
|
Facility
|
OP
|
$2,961.24
|
|
|
Service Code
|
HCPCS 49441
|
| Hospital Charge Code |
761T2005
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.96 |
| Max. Negotiated Rate |
$2,842.79 |
| Rate for Payer: Aetna Commercial |
$2,280.15
|
| Rate for Payer: Anthem Medicaid |
$1,018.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,309.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$1,480.62
|
| Rate for Payer: Cash Price |
$1,480.62
|
| Rate for Payer: Cigna Commercial |
$2,457.83
|
| Rate for Payer: First Health Commercial |
$2,813.18
|
| Rate for Payer: Humana Commercial |
$2,517.05
|
| Rate for Payer: Humana KY Medicaid |
$1,018.37
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,028.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,428.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,185.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,038.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,605.89
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$592.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$917.98
|
| Rate for Payer: PHCS Commercial |
$2,842.79
|
| Rate for Payer: United Healthcare All Payer |
$2,605.89
|
|
|
PLACE GASTROSTOMY TUBE PERC
|
Professional
|
Both
|
$1,080.00
|
|
|
Service Code
|
HCPCS 49440
|
| Hospital Charge Code |
76102698
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.26 |
| Max. Negotiated Rate |
$1,335.12 |
| Rate for Payer: Aetna Commercial |
$378.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$204.18
|
| Rate for Payer: Anthem Medicaid |
$192.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,080.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna Commercial |
$344.84
|
| Rate for Payer: Healthspan PPO |
$1,335.12
|
| Rate for Payer: Humana Medicaid |
$192.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$296.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$196.11
|
| Rate for Payer: Molina Healthcare Passport |
$192.26
|
| Rate for Payer: Multiplan PHCS |
$648.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$756.00
|
| Rate for Payer: UHCCP Medicaid |
$214.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.18
|
|
|
PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION
|
Facility
|
OP
|
$2,465.88
|
|
|
Service Code
|
CPT 50432
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,761.34 |
| Max. Negotiated Rate |
$2,465.88 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,761.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,465.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,377.81
|
| Rate for Payer: Humana Medicare Advantage |
$1,761.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.61
|
|
|
PLACEMENT OF SETON
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
HCPCS 46020
|
| Hospital Charge Code |
76102863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$309.53 |
| Rate for Payer: Aetna Commercial |
$309.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.35
|
| Rate for Payer: Anthem Medicaid |
$149.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$140.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$282.61
|
| Rate for Payer: Healthspan PPO |
$295.34
|
| Rate for Payer: Humana Medicaid |
$149.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$285.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$152.88
|
| Rate for Payer: Molina Healthcare Passport |
$149.88
|
| Rate for Payer: Multiplan PHCS |
$84.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.00
|
| Rate for Payer: UHCCP Medicaid |
$124.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.38
|
|
|
PLACEMENT OF SETON
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 46020
|
| Hospital Charge Code |
76102863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$3,399.27 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem Medicaid |
$48.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,428.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,399.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,277.87
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Humana KY Medicaid |
$48.15
|
| Rate for Payer: Humana Medicare Advantage |
$2,428.05
|
| Rate for Payer: Kentucky WC Medicaid |
$48.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,913.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
PLACEMENT OF SETON
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 46020
|
| Hospital Charge Code |
76102863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
PLACE OF CATH FOR BRACHYTHERAP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 31643
|
| Hospital Charge Code |
41000051
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$148.43 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$296.60
|
| Rate for Payer: Anthem Medicaid |
$148.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$269.19
|
| Rate for Payer: Healthspan PPO |
$231.58
|
| Rate for Payer: Humana Medicaid |
$148.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$225.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$151.40
|
| Rate for Payer: Molina Healthcare Passport |
$148.43
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.91
|
|
|
PLACE OF CATH FOR BRACHYTHERAP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 31643
|
| Hospital Charge Code |
410P0051
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$148.43 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$296.60
|
| Rate for Payer: Anthem Medicaid |
$148.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$269.19
|
| Rate for Payer: Healthspan PPO |
$231.58
|
| Rate for Payer: Humana Medicaid |
$148.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$225.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$151.40
|
| Rate for Payer: Molina Healthcare Passport |
$148.43
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.91
|
|
|
PLACE RADIOTHER BALLOON CATH
|
Facility
|
OP
|
$4,010.50
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
76100298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$521.36 |
| Max. Negotiated Rate |
$3,850.08 |
| Rate for Payer: Aetna Commercial |
$3,088.08
|
| Rate for Payer: Anthem Medicaid |
$1,379.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,128.19
|
| Rate for Payer: Cash Price |
$2,005.25
|
| Rate for Payer: Cigna Commercial |
$3,328.72
|
| Rate for Payer: First Health Commercial |
$3,809.98
|
| Rate for Payer: Humana Commercial |
$3,408.92
|
| Rate for Payer: Humana KY Medicaid |
$1,379.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,393.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,288.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,959.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,203.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,529.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,007.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$802.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.26
|
| Rate for Payer: PHCS Commercial |
$3,850.08
|
| Rate for Payer: United Healthcare All Payer |
$3,529.24
|
|
|
PLACE RADIOTHER BALLOON CATH
|
Facility
|
IP
|
$4,010.50
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
76100298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$521.36 |
| Max. Negotiated Rate |
$3,850.08 |
| Rate for Payer: Aetna Commercial |
$3,088.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,128.19
|
| Rate for Payer: Cash Price |
$2,005.25
|
| Rate for Payer: Cigna Commercial |
$3,328.72
|
| Rate for Payer: First Health Commercial |
$3,809.98
|
| Rate for Payer: Humana Commercial |
$3,408.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,288.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,959.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,203.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,529.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,007.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$802.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.26
|
| Rate for Payer: PHCS Commercial |
$3,850.08
|
| Rate for Payer: United Healthcare All Payer |
$3,529.24
|
|
|
PLACE RADIOTHER BALLOON CATH
|
Professional
|
Both
|
$4,010.50
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
76100298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.90 |
| Max. Negotiated Rate |
$4,010.50 |
| Rate for Payer: Aetna Commercial |
$138.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,010.50
|
| Rate for Payer: Cash Price |
$2,005.25
|
| Rate for Payer: Cash Price |
$2,005.25
|
| Rate for Payer: Cigna Commercial |
$134.24
|
| Rate for Payer: Healthspan PPO |
$110.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.01
|
| Rate for Payer: Multiplan PHCS |
$2,406.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,807.35
|
| Rate for Payer: UHCCP Medicaid |
$1,403.68
|
|
|
PLACE RADIOTHER BALLOON CATH(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
761P0298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$138.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$134.24
|
| Rate for Payer: Healthspan PPO |
$110.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.01
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
PLACE RADIOTHER BALLOON CATH(T
|
Facility
|
OP
|
$3,810.50
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
761T0298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$495.36 |
| Max. Negotiated Rate |
$3,658.08 |
| Rate for Payer: Aetna Commercial |
$2,934.08
|
| Rate for Payer: Anthem Medicaid |
$1,310.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,972.19
|
| Rate for Payer: Cash Price |
$1,905.25
|
| Rate for Payer: Cigna Commercial |
$3,162.72
|
| Rate for Payer: First Health Commercial |
$3,619.98
|
| Rate for Payer: Humana Commercial |
$3,238.92
|
| Rate for Payer: Humana KY Medicaid |
$1,310.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,323.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,124.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,812.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,143.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,336.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,353.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,857.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,181.26
|
| Rate for Payer: PHCS Commercial |
$3,658.08
|
| Rate for Payer: United Healthcare All Payer |
$3,353.24
|
|
|
PLACE RADIOTHER BALLOON CATH(T
|
Facility
|
IP
|
$3,810.50
|
|
|
Service Code
|
HCPCS 19297
|
| Hospital Charge Code |
761T0298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$495.36 |
| Max. Negotiated Rate |
$3,658.08 |
| Rate for Payer: Aetna Commercial |
$2,934.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,972.19
|
| Rate for Payer: Cash Price |
$1,905.25
|
| Rate for Payer: Cigna Commercial |
$3,162.72
|
| Rate for Payer: First Health Commercial |
$3,619.98
|
| Rate for Payer: Humana Commercial |
$3,238.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,124.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,812.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,143.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,353.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,857.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,181.26
|
| Rate for Payer: PHCS Commercial |
$3,658.08
|
| Rate for Payer: United Healthcare All Payer |
$3,353.24
|
|
|
PLACE RT DEVICE/MARKER PROS
|
Facility
|
IP
|
$3,948.41
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
76102153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$513.29 |
| Max. Negotiated Rate |
$3,790.47 |
| Rate for Payer: Aetna Commercial |
$3,040.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,079.76
|
| Rate for Payer: Cash Price |
$1,974.20
|
| Rate for Payer: Cigna Commercial |
$3,277.18
|
| Rate for Payer: First Health Commercial |
$3,750.99
|
| Rate for Payer: Humana Commercial |
$3,356.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,237.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,913.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,184.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,961.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.01
|
| Rate for Payer: PHCS Commercial |
$3,790.47
|
| Rate for Payer: United Healthcare All Payer |
$3,474.60
|
|
|
PLACE RT DEVICE/MARKER PROS
|
Professional
|
Both
|
$3,948.41
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
76102153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$3,948.41 |
| Rate for Payer: Aetna Commercial |
$178.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$59.55
|
| Rate for Payer: Anthem Medicaid |
$83.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,948.41
|
| Rate for Payer: Cash Price |
$1,974.20
|
| Rate for Payer: Cash Price |
$1,974.20
|
| Rate for Payer: Cigna Commercial |
$220.44
|
| Rate for Payer: Healthspan PPO |
$224.30
|
| Rate for Payer: Humana Medicaid |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$137.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.71
|
| Rate for Payer: Molina Healthcare Passport |
$83.05
|
| Rate for Payer: Multiplan PHCS |
$2,369.05
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,763.89
|
| Rate for Payer: UHCCP Medicaid |
$62.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$83.88
|
|
|
PLACE RT DEVICE/MARKER PROS
|
Facility
|
OP
|
$3,948.41
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
76102153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$513.29 |
| Max. Negotiated Rate |
$3,790.47 |
| Rate for Payer: Aetna Commercial |
$3,040.28
|
| Rate for Payer: Anthem Medicaid |
$1,357.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,198.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,079.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,677.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,617.60
|
| Rate for Payer: Cash Price |
$1,974.20
|
| Rate for Payer: Cash Price |
$1,974.20
|
| Rate for Payer: Cigna Commercial |
$3,277.18
|
| Rate for Payer: First Health Commercial |
$3,750.99
|
| Rate for Payer: Humana Commercial |
$3,356.15
|
| Rate for Payer: Humana KY Medicaid |
$1,357.86
|
| Rate for Payer: Humana Medicare Advantage |
$1,198.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,371.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,237.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,913.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,437.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,961.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.01
|
| Rate for Payer: PHCS Commercial |
$3,790.47
|
| Rate for Payer: United Healthcare All Payer |
$3,474.60
|
|
|
PLACE RT DEVICE/MARKER PROS(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
761P2153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.55 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$178.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$59.55
|
| Rate for Payer: Anthem Medicaid |
$83.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$220.44
|
| Rate for Payer: Healthspan PPO |
$224.30
|
| Rate for Payer: Humana Medicaid |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$137.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.71
|
| Rate for Payer: Molina Healthcare Passport |
$83.05
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$62.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$83.88
|
|
|
PLACE RT DEVICE/MARKER PROS(T
|
Facility
|
IP
|
$3,573.41
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
761T2153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$464.54 |
| Max. Negotiated Rate |
$3,430.47 |
| Rate for Payer: Aetna Commercial |
$2,751.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,787.26
|
| Rate for Payer: Cash Price |
$1,786.70
|
| Rate for Payer: Cigna Commercial |
$2,965.93
|
| Rate for Payer: First Health Commercial |
$3,394.74
|
| Rate for Payer: Humana Commercial |
$3,037.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,930.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,637.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,144.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,680.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$714.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,107.76
|
| Rate for Payer: PHCS Commercial |
$3,430.47
|
| Rate for Payer: United Healthcare All Payer |
$3,144.60
|
|
|
PLACE RT DEVICE/MARKER PROS(T
|
Facility
|
OP
|
$3,573.41
|
|
|
Service Code
|
HCPCS 55876
|
| Hospital Charge Code |
761T2153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$464.54 |
| Max. Negotiated Rate |
$3,430.47 |
| Rate for Payer: Aetna Commercial |
$2,751.53
|
| Rate for Payer: Anthem Medicaid |
$1,228.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,198.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,787.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,677.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,617.60
|
| Rate for Payer: Cash Price |
$1,786.70
|
| Rate for Payer: Cash Price |
$1,786.70
|
| Rate for Payer: Cigna Commercial |
$2,965.93
|
| Rate for Payer: First Health Commercial |
$3,394.74
|
| Rate for Payer: Humana Commercial |
$3,037.40
|
| Rate for Payer: Humana KY Medicaid |
$1,228.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,198.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,930.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,637.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,437.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,253.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,144.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,680.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$714.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,107.76
|
| Rate for Payer: PHCS Commercial |
$3,430.47
|
| Rate for Payer: United Healthcare All Payer |
$3,144.60
|
|
|
PLANT PROFYLE REPLANT 4*2H
|
Facility
|
OP
|
$4,274.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.72 |
| Max. Negotiated Rate |
$4,103.81 |
| Rate for Payer: Aetna Commercial |
$3,291.60
|
| Rate for Payer: Anthem Medicaid |
$1,470.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,334.34
|
| Rate for Payer: Cash Price |
$2,137.40
|
| Rate for Payer: Cigna Commercial |
$3,548.08
|
| Rate for Payer: First Health Commercial |
$4,061.06
|
| Rate for Payer: Humana Commercial |
$3,633.58
|
| Rate for Payer: Humana KY Medicaid |
$1,470.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,485.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,505.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,154.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,282.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,499.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,761.82
|
| Rate for Payer: Ohio Health Group HMO |
$3,206.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$854.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,325.19
|
| Rate for Payer: PHCS Commercial |
$4,103.81
|
| Rate for Payer: United Healthcare All Payer |
$3,761.82
|
|
|
PLANT PROFYLE REPLANT 4*2H
|
Facility
|
IP
|
$4,274.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.72 |
| Max. Negotiated Rate |
$4,103.81 |
| Rate for Payer: Aetna Commercial |
$3,291.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,334.34
|
| Rate for Payer: Cash Price |
$2,137.40
|
| Rate for Payer: Cigna Commercial |
$3,548.08
|
| Rate for Payer: First Health Commercial |
$4,061.06
|
| Rate for Payer: Humana Commercial |
$3,633.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,505.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,154.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,282.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,761.82
|
| Rate for Payer: Ohio Health Group HMO |
$3,206.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$854.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,325.19
|
| Rate for Payer: PHCS Commercial |
$4,103.81
|
| Rate for Payer: United Healthcare All Payer |
$3,761.82
|
|
|
PLAQUENIL(HYDROXYCH 200MG/1TAB
|
Facility
|
OP
|
$9.95
|
|
|
Service Code
|
NDC 68084026901
|
| Hospital Charge Code |
25001190
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.55 |
| Rate for Payer: Aetna Commercial |
$7.66
|
| Rate for Payer: Anthem Medicaid |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.76
|
| Rate for Payer: Cash Price |
$4.97
|
| Rate for Payer: Cigna Commercial |
$8.26
|
| Rate for Payer: First Health Commercial |
$9.45
|
| Rate for Payer: Humana Commercial |
$8.46
|
| Rate for Payer: Humana KY Medicaid |
$3.42
|
| Rate for Payer: Kentucky WC Medicaid |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.76
|
| Rate for Payer: Ohio Health Group HMO |
$7.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$9.55
|
| Rate for Payer: United Healthcare All Payer |
$8.76
|
|
|
PLAQUENIL(HYDROXYCH 200MG/1TAB
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 68084026901
|
| Hospital Charge Code |
25001190
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.55 |
| Rate for Payer: Aetna Commercial |
$7.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.76
|
| Rate for Payer: Cash Price |
$4.97
|
| Rate for Payer: Cigna Commercial |
$8.26
|
| Rate for Payer: First Health Commercial |
$9.45
|
| Rate for Payer: Humana Commercial |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.76
|
| Rate for Payer: Ohio Health Group HMO |
$7.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$9.55
|
| Rate for Payer: United Healthcare All Payer |
$8.76
|
|
