|
PERQ&IC ALLG TEST DRUGS/BIOL
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
41000105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem Medicaid |
$46.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Humana KY Medicaid |
$46.08
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$46.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.46
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
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 |
$37.08 |
| Rate for Payer: Ambetter Exchange |
$6.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.66
|
| Rate for Payer: Anthem Medicaid |
$22.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$6.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$6.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.96
|
| 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 |
$22.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$6.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$23.05
|
| Rate for Payer: Molina Healthcare Passport |
$22.60
|
| Rate for Payer: Multiplan PHCS |
$34.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8.62
|
| Rate for Payer: UHCCP Medicaid |
$5.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$6.63
|
|
|
PERQ&IC ALLG TEST DRUGS/BIO(T
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
410T0105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$23.10 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.06
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.13
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
PERQ&IC ALLG TEST DRUGS/BIO(T
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS 95018
|
| Hospital Charge Code |
410T0105
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$73.92 |
| Rate for Payer: Aetna Commercial |
$59.29
|
| Rate for Payer: Anthem Medicaid |
$26.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: Cigna Commercial |
$63.91
|
| Rate for Payer: First Health Commercial |
$73.15
|
| Rate for Payer: Humana Commercial |
$65.45
|
| Rate for Payer: Humana KY Medicaid |
$26.48
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$26.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.76
|
| Rate for Payer: Ohio Health Group HMO |
$57.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.13
|
| Rate for Payer: PHCS Commercial |
$73.92
|
| Rate for Payer: United Healthcare All Payer |
$67.76
|
|
|
PERQ LUMBOSACRAL INJECTION
|
Facility
|
IP
|
$10,883.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
76100422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$3,264.90 |
| 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 |
$8,706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,468.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,509.27
|
| 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 |
$2,997.95 |
| 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 |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,488.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$8,706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,468.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,509.27
|
| 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 |
$6,529.80 |
| Rate for Payer: Ambetter Exchange |
$383.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.17
|
| Rate for Payer: Anthem Medicaid |
$1,311.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$383.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$383.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$460.60
|
| 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 |
$1,311.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$383.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,337.28
|
| Rate for Payer: Molina Healthcare Passport |
$1,311.06
|
| Rate for Payer: Multiplan PHCS |
$6,529.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$498.98
|
| Rate for Payer: UHCCP Medicaid |
$348.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,324.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$383.83
|
|
|
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 |
$2,160.00 |
| Rate for Payer: Ambetter Exchange |
$383.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.17
|
| Rate for Payer: Anthem Medicaid |
$1,311.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$383.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$383.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$460.60
|
| 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 |
$1,311.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$383.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,337.28
|
| Rate for Payer: Molina Healthcare Passport |
$1,311.06
|
| Rate for Payer: Multiplan PHCS |
$2,160.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$498.98
|
| Rate for Payer: UHCCP Medicaid |
$348.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,324.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$383.83
|
|
|
PERQ LUMBOSACRAL INJECTION(T
|
Facility
|
IP
|
$7,283.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
761T0422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,184.90 |
| 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 |
$5,826.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,336.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,025.27
|
| Rate for Payer: PHCS Commercial |
$6,991.68
|
| Rate for Payer: United Healthcare All Payer |
$6,409.04
|
|
|
PERQ LUMBOSACRAL INJECTION(T
|
Facility
|
OP
|
$7,283.00
|
|
|
Service Code
|
HCPCS 22511
|
| Hospital Charge Code |
761T0422
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,504.62 |
| 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 |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,680.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$5,826.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,336.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,025.27
|
| 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 |
$6,246.94 |
| 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 |
$8,544.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,168.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,961.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,534.64
|
| 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 |
$8,544.18
|
| 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 |
$10,253.02
|
| 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 |
$14,532.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,803.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,533.85
|
| 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 |
$10,899.00 |
| Rate for Payer: Aetna Commercial |
$2,093.39
|
| Rate for Payer: Ambetter Exchange |
$1,060.80
|
| Rate for Payer: Anthem Medicaid |
$1,040.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,060.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,060.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,272.96
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,060.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,060.80
|
| 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 |
$1,379.04
|
| Rate for Payer: UHCCP Medicaid |
$6,357.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,050.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,060.80
|
|
|
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 |
$5,449.50 |
| 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 |
$14,532.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,803.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,533.85
|
| 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 |
$2,093.39 |
| Rate for Payer: Aetna Commercial |
$2,093.39
|
| Rate for Payer: Ambetter Exchange |
$1,060.80
|
| Rate for Payer: Anthem Medicaid |
$1,040.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,060.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,060.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,272.96
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,060.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,060.80
|
| 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 |
$1,379.04
|
| Rate for Payer: UHCCP Medicaid |
$962.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,050.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,060.80
|
|
|
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 |
$4,624.50 |
| 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 |
$12,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,411.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,636.35
|
| 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
|
OP
|
$15,415.00
|
|
|
Service Code
|
HCPCS 50081
|
| Hospital Charge Code |
761T2875
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$5,301.22 |
| 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 |
$8,544.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,023.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,961.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,534.64
|
| 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 |
$8,544.18
|
| 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 |
$10,253.02
|
| 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 |
$12,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,411.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,636.35
|
| Rate for Payer: PHCS Commercial |
$14,798.40
|
| Rate for Payer: United Healthcare All Payer |
$13,565.20
|
|
|
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 |
$4,813.50 |
| 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 |
$12,836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,959.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,071.05
|
| 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 |
$5,517.88 |
| 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 |
$8,544.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,515.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,961.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,534.64
|
| 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 |
$8,544.18
|
| 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 |
$10,253.02
|
| 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 |
$12,836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,959.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,071.05
|
| Rate for Payer: PHCS Commercial |
$15,403.20
|
| Rate for Payer: United Healthcare All Payer |
$14,119.60
|
|
|
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 |
$658.44 |
| Max. Negotiated Rate |
$9,627.00 |
| Rate for Payer: Aetna Commercial |
$1,424.28
|
| Rate for Payer: Ambetter Exchange |
$658.44
|
| Rate for Payer: Anthem Medicaid |
$765.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$658.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$658.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$790.13
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$658.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$658.44
|
| 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 |
$855.97
|
| Rate for Payer: UHCCP Medicaid |
$5,615.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$773.04
|
| Rate for Payer: Wellcare Medicare Advantage |
$658.44
|
|
|
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 |
$1,424.28 |
| Rate for Payer: Aetna Commercial |
$1,424.28
|
| Rate for Payer: Ambetter Exchange |
$658.44
|
| Rate for Payer: Anthem Medicaid |
$765.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$658.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$658.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$790.13
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$658.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$658.44
|
| 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 |
$855.97
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$773.04
|
| Rate for Payer: Wellcare Medicare Advantage |
$658.44
|
|
|
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 |
$4,933.25 |
| 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 |
$8,544.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,189.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,961.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,534.64
|
| 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 |
$8,544.18
|
| 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 |
$10,253.02
|
| 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 |
$11,476.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,480.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,898.05
|
| 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
|
IP
|
$14,345.00
|
|
|
Service Code
|
HCPCS 50080
|
| Hospital Charge Code |
761T2874
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$4,303.50 |
| 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 |
$11,476.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,480.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,898.05
|
| Rate for Payer: PHCS Commercial |
$13,771.20
|
| Rate for Payer: United Healthcare All Payer |
$12,623.60
|
|
|
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 |
$406.48 |
| Max. Negotiated Rate |
$6,712.80 |
| Rate for Payer: Ambetter Exchange |
$406.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$432.53
|
| Rate for Payer: Anthem Medicaid |
$3,789.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$406.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$406.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$487.78
|
| 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 |
$3,789.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$751.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$406.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$406.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,865.65
|
| Rate for Payer: Molina Healthcare Passport |
$3,789.85
|
| Rate for Payer: Multiplan PHCS |
$6,712.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$528.42
|
| Rate for Payer: UHCCP Medicaid |
$454.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,827.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$406.48
|
|
|
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 |
$3,712.51 |
| Rate for Payer: Ambetter Exchange |
$393.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$362.03
|
| Rate for Payer: Anthem Medicaid |
$3,639.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$393.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$393.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$472.01
|
| 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 |
$3,639.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$393.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$393.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,712.51
|
| Rate for Payer: Molina Healthcare Passport |
$3,639.72
|
| Rate for Payer: Multiplan PHCS |
$2,526.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$511.34
|
| Rate for Payer: UHCCP Medicaid |
$380.13
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,676.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$393.34
|
|
|
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 |
$1,263.00 |
| 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 |
$3,368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.90
|
| Rate for Payer: PHCS Commercial |
$4,041.60
|
| Rate for Payer: United Healthcare All Payer |
$3,704.80
|
|
