|
POLIO 1 TITER
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001095
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
POLIO 1 TITER
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001095
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$16.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.91
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$16.91
|
| Rate for Payer: Humana Medicare Advantage |
$16.91
|
| Rate for Payer: Kentucky WC Medicaid |
$17.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
POLIO 2 TITER
|
Facility
|
OP
|
$346.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001094
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$332.16 |
| Rate for Payer: Aetna Commercial |
$266.42
|
| Rate for Payer: Anthem Medicaid |
$16.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.91
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$287.18
|
| Rate for Payer: First Health Commercial |
$328.70
|
| Rate for Payer: Humana Commercial |
$294.10
|
| Rate for Payer: Humana KY Medicaid |
$16.91
|
| Rate for Payer: Humana Medicare Advantage |
$16.91
|
| Rate for Payer: Kentucky WC Medicaid |
$17.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$283.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$255.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$304.48
|
| Rate for Payer: Ohio Health Group HMO |
$259.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$276.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$301.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.74
|
| Rate for Payer: PHCS Commercial |
$332.16
|
| Rate for Payer: United Healthcare All Payer |
$304.48
|
|
|
POLIO 2 TITER
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001094
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.80 |
| Max. Negotiated Rate |
$332.16 |
| Rate for Payer: Aetna Commercial |
$266.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$277.84
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$287.18
|
| Rate for Payer: First Health Commercial |
$328.70
|
| Rate for Payer: Humana Commercial |
$294.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$283.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$255.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$304.48
|
| Rate for Payer: Ohio Health Group HMO |
$259.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$276.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$301.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$238.74
|
| Rate for Payer: PHCS Commercial |
$332.16
|
| Rate for Payer: United Healthcare All Payer |
$304.48
|
|
|
POLIO 3 TITER
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$16.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.91
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$16.91
|
| Rate for Payer: Humana Medicare Advantage |
$16.91
|
| Rate for Payer: Kentucky WC Medicaid |
$17.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
POLIO 3 TITER
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 86382
|
| Hospital Charge Code |
30001093
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
77000041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Anthem Medicaid |
$35.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$35.26
|
| Rate for Payer: Humana Medicaid |
$35.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.70
|
| Rate for Payer: Molina Healthcare Passport |
$35.00
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.35
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
770T0041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.59
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
770T0041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
77000041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.59
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
77000041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLYETHYLENE LINER 52MM*40MM
|
Facility
|
OP
|
$5,431.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.38 |
| Max. Negotiated Rate |
$5,214.00 |
| Rate for Payer: Aetna Commercial |
$4,182.06
|
| Rate for Payer: Anthem Medicaid |
$1,867.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,236.38
|
| Rate for Payer: Cash Price |
$2,715.62
|
| Rate for Payer: Cigna Commercial |
$4,507.94
|
| Rate for Payer: First Health Commercial |
$5,159.69
|
| Rate for Payer: Humana Commercial |
$4,616.56
|
| Rate for Payer: Humana KY Medicaid |
$1,867.81
|
| Rate for Payer: Kentucky WC Medicaid |
$1,886.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,453.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,008.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,629.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,905.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,779.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,073.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,725.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.56
|
| Rate for Payer: PHCS Commercial |
$5,214.00
|
| Rate for Payer: United Healthcare All Payer |
$4,779.50
|
|
|
POLYETHYLENE LINER 52MM*40MM
|
Facility
|
IP
|
$5,431.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.38 |
| Max. Negotiated Rate |
$5,214.00 |
| Rate for Payer: Aetna Commercial |
$4,182.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,236.38
|
| Rate for Payer: Cash Price |
$2,715.62
|
| Rate for Payer: Cigna Commercial |
$4,507.94
|
| Rate for Payer: First Health Commercial |
$5,159.69
|
| Rate for Payer: Humana Commercial |
$4,616.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,453.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,008.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,629.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,779.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,073.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,725.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,747.56
|
| Rate for Payer: PHCS Commercial |
$5,214.00
|
| Rate for Payer: United Healthcare All Payer |
$4,779.50
|
|
|
POLYMYXIN B SULFAT 500000U/1EA
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003359
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
POLYMYXIN B SULFAT 500000U/1EA
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003359
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Facility
|
IP
|
$5,343.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,602.90 |
| Max. Negotiated Rate |
$5,129.28 |
| Rate for Payer: Aetna Commercial |
$4,114.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,167.54
|
| Rate for Payer: Cash Price |
$2,671.50
|
| Rate for Payer: Cigna Commercial |
$4,434.69
|
| Rate for Payer: First Health Commercial |
$5,075.85
|
| Rate for Payer: Humana Commercial |
$4,541.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,381.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,943.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,602.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,701.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,007.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,274.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,648.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,686.67
|
| Rate for Payer: PHCS Commercial |
$5,129.28
|
| Rate for Payer: United Healthcare All Payer |
$4,701.84
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Professional
|
Both
|
$5,343.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$150.32 |
| Max. Negotiated Rate |
$3,205.80 |
| Rate for Payer: Aetna Commercial |
$1,164.16
|
| Rate for Payer: Ambetter Exchange |
$562.43
|
| Rate for Payer: Anthem Medicaid |
$542.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$562.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$562.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$674.92
|
| Rate for Payer: Cash Price |
$2,671.50
|
| Rate for Payer: Cash Price |
$2,671.50
|
| Rate for Payer: Cigna Commercial |
$1,218.77
|
| Rate for Payer: Healthspan PPO |
$1,018.12
|
| Rate for Payer: Humana Medicaid |
$542.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$562.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$553.27
|
| Rate for Payer: Molina Healthcare Passport |
$542.42
|
| Rate for Payer: Multiplan PHCS |
$3,205.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$731.16
|
| Rate for Payer: UHCCP Medicaid |
$1,870.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$547.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$562.43
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Facility
|
OP
|
$5,343.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$940.05 |
| Max. Negotiated Rate |
$5,129.28 |
| Rate for Payer: Aetna Commercial |
$4,114.11
|
| Rate for Payer: Anthem Medicaid |
$1,837.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$940.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,167.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,316.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,269.07
|
| Rate for Payer: Cash Price |
$2,671.50
|
| Rate for Payer: Cash Price |
$2,671.50
|
| Rate for Payer: Cigna Commercial |
$4,434.69
|
| Rate for Payer: First Health Commercial |
$5,075.85
|
| Rate for Payer: Humana Commercial |
$4,541.55
|
| Rate for Payer: Humana KY Medicaid |
$1,837.46
|
| Rate for Payer: Humana Medicare Advantage |
$940.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,856.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,381.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,943.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,128.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,874.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,701.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,007.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,274.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,648.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,686.67
|
| Rate for Payer: PHCS Commercial |
$5,129.28
|
| Rate for Payer: United Healthcare All Payer |
$4,701.84
|
|
|
POLYSOMNOGRAPHY MON <6HR(P
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740P0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$1,218.77 |
| Rate for Payer: Aetna Commercial |
$1,164.16
|
| Rate for Payer: Ambetter Exchange |
$562.43
|
| Rate for Payer: Anthem Medicaid |
$542.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$562.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$562.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$674.92
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$1,218.77
|
| Rate for Payer: Healthspan PPO |
$1,018.12
|
| Rate for Payer: Humana Medicaid |
$542.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$562.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$553.27
|
| Rate for Payer: Molina Healthcare Passport |
$542.42
|
| Rate for Payer: Multiplan PHCS |
$189.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$731.16
|
| Rate for Payer: UHCCP Medicaid |
$110.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$547.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$562.43
|
|
|
POLYSOMNOGRAPHY MON <6HR(T
|
Facility
|
IP
|
$5,028.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740T0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,508.40 |
| Max. Negotiated Rate |
$4,826.88 |
| Rate for Payer: Aetna Commercial |
$3,871.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,921.84
|
| Rate for Payer: Cash Price |
$2,514.00
|
| Rate for Payer: Cigna Commercial |
$4,173.24
|
| Rate for Payer: First Health Commercial |
$4,776.60
|
| Rate for Payer: Humana Commercial |
$4,273.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,122.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,710.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,508.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,424.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,771.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,022.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,374.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,469.32
|
| Rate for Payer: PHCS Commercial |
$4,826.88
|
| Rate for Payer: United Healthcare All Payer |
$4,424.64
|
|
|
POLYSOMNOGRAPHY MON <6HR(T
|
Facility
|
OP
|
$5,028.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740T0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$940.05 |
| Max. Negotiated Rate |
$4,826.88 |
| Rate for Payer: Aetna Commercial |
$3,871.56
|
| Rate for Payer: Anthem Medicaid |
$1,729.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$940.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,921.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,316.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,269.07
|
| Rate for Payer: Cash Price |
$2,514.00
|
| Rate for Payer: Cash Price |
$2,514.00
|
| Rate for Payer: Cigna Commercial |
$4,173.24
|
| Rate for Payer: First Health Commercial |
$4,776.60
|
| Rate for Payer: Humana Commercial |
$4,273.80
|
| Rate for Payer: Humana KY Medicaid |
$1,729.13
|
| Rate for Payer: Humana Medicare Advantage |
$940.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,746.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,122.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,710.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,128.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,763.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,424.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,771.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,022.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,374.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,469.32
|
| Rate for Payer: PHCS Commercial |
$4,826.88
|
| Rate for Payer: United Healthcare All Payer |
$4,424.64
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Facility
|
IP
|
$6,204.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,861.20 |
| Max. Negotiated Rate |
$5,955.84 |
| Rate for Payer: Aetna Commercial |
$4,777.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,839.12
|
| Rate for Payer: Cash Price |
$3,102.00
|
| Rate for Payer: Cigna Commercial |
$5,149.32
|
| Rate for Payer: First Health Commercial |
$5,893.80
|
| Rate for Payer: Humana Commercial |
$5,273.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,087.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,578.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,861.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,459.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,653.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,963.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,397.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,280.76
|
| Rate for Payer: PHCS Commercial |
$5,955.84
|
| Rate for Payer: United Healthcare All Payer |
$5,459.52
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Facility
|
OP
|
$6,204.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$940.05 |
| Max. Negotiated Rate |
$5,955.84 |
| Rate for Payer: Aetna Commercial |
$4,777.08
|
| Rate for Payer: Anthem Medicaid |
$2,133.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$940.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,839.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,316.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,269.07
|
| Rate for Payer: Cash Price |
$3,102.00
|
| Rate for Payer: Cash Price |
$3,102.00
|
| Rate for Payer: Cigna Commercial |
$5,149.32
|
| Rate for Payer: First Health Commercial |
$5,893.80
|
| Rate for Payer: Humana Commercial |
$5,273.40
|
| Rate for Payer: Humana KY Medicaid |
$2,133.56
|
| Rate for Payer: Humana Medicare Advantage |
$940.05
|
| Rate for Payer: Kentucky WC Medicaid |
$2,155.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,087.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,578.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,128.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,176.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,459.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,653.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,963.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,397.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,280.76
|
| Rate for Payer: PHCS Commercial |
$5,955.84
|
| Rate for Payer: United Healthcare All Payer |
$5,459.52
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Professional
|
Both
|
$6,204.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$157.27 |
| Max. Negotiated Rate |
$3,722.40 |
| Rate for Payer: Aetna Commercial |
$1,281.26
|
| Rate for Payer: Ambetter Exchange |
$589.02
|
| Rate for Payer: Anthem Medicaid |
$597.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$589.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$589.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$706.82
|
| Rate for Payer: Cash Price |
$3,102.00
|
| Rate for Payer: Cash Price |
$3,102.00
|
| Rate for Payer: Cigna Commercial |
$1,335.20
|
| Rate for Payer: Healthspan PPO |
$1,120.53
|
| Rate for Payer: Humana Medicaid |
$597.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$589.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.79
|
| Rate for Payer: Molina Healthcare Passport |
$597.83
|
| Rate for Payer: Multiplan PHCS |
$3,722.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$765.73
|
| Rate for Payer: UHCCP Medicaid |
$2,171.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$589.02
|
|
|
POLYSOMNOMON W C/BPAP<6HR(P
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740P0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$117.25 |
| Max. Negotiated Rate |
$1,335.20 |
| Rate for Payer: Aetna Commercial |
$1,281.26
|
| Rate for Payer: Ambetter Exchange |
$589.02
|
| Rate for Payer: Anthem Medicaid |
$597.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$589.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$589.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$706.82
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$1,335.20
|
| Rate for Payer: Healthspan PPO |
$1,120.53
|
| Rate for Payer: Humana Medicaid |
$597.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$589.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.79
|
| Rate for Payer: Molina Healthcare Passport |
$597.83
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$765.73
|
| Rate for Payer: UHCCP Medicaid |
$117.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$589.02
|
|
