|
SC EUPHORA RX BALLOON 4.00*30
|
Facility
|
IP
|
$1,547.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$1,485.60 |
| Rate for Payer: Aetna Commercial |
$1,191.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,207.05
|
| Rate for Payer: Cash Price |
$773.75
|
| Rate for Payer: Cigna Commercial |
$1,284.42
|
| Rate for Payer: First Health Commercial |
$1,470.12
|
| Rate for Payer: Humana Commercial |
$1,315.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,268.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,142.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,361.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,160.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$479.72
|
| Rate for Payer: PHCS Commercial |
$1,485.60
|
| Rate for Payer: United Healthcare All Payer |
$1,361.80
|
|
|
SC EUPHORA RX BALLOON 4.00*30
|
Facility
|
OP
|
$1,547.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$1,485.60 |
| Rate for Payer: Aetna Commercial |
$1,191.58
|
| Rate for Payer: Anthem Medicaid |
$532.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,207.05
|
| Rate for Payer: Cash Price |
$773.75
|
| Rate for Payer: Cigna Commercial |
$1,284.42
|
| Rate for Payer: First Health Commercial |
$1,470.12
|
| Rate for Payer: Humana Commercial |
$1,315.38
|
| Rate for Payer: Humana KY Medicaid |
$532.19
|
| Rate for Payer: Kentucky WC Medicaid |
$537.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,268.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,142.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$542.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,361.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,160.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$479.72
|
| Rate for Payer: PHCS Commercial |
$1,485.60
|
| Rate for Payer: United Healthcare All Payer |
$1,361.80
|
|
|
SCHOOL PHYSICIAL
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$31.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Humana KY Medicaid |
$31.29
|
| Rate for Payer: Kentucky WC Medicaid |
$31.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.21
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SCHOOL PHYSICIAL
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$91.00
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$54.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.70
|
| Rate for Payer: UHCCP Medicaid |
$31.85
|
|
|
SCHOOL PHYSICIAL
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.21
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SCHOOL PHYSICIAL(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510P0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
SCHOOL PHYSICIAL(T
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510T0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$17.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Humana KY Medicaid |
$17.54
|
| Rate for Payer: Kentucky WC Medicaid |
$17.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
SCHOOL PHYSICIAL(T
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510T0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.81
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
SCLEROTHERAPY SPIDER VEINS
|
Professional
|
Both
|
$785.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
76101460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$785.00 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$785.00
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.04
|
| Rate for Payer: Multiplan PHCS |
$471.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$549.50
|
| Rate for Payer: UHCCP Medicaid |
$274.75
|
|
|
SCLEROTHERAPY SPIDER VEINS
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
76101460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$102.05 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem Medicaid |
$269.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Humana KY Medicaid |
$269.96
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$272.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.35
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
SCLEROTHERAPY SPIDER VEINS
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
76101460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$102.05 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.35
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
SCLEROTHERAPY SPIDER VEINS(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
761P1460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$108.86
|
| 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: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.04
|
| 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
|
|
|
SCLEROTHERAPY SPIDER VEINS(T
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
761T1460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.05 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem Medicaid |
$201.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Humana KY Medicaid |
$201.18
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$203.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.35
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
SCLEROTHERAPY SPIDER VEINS(T
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
761T1460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.05 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.35
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
SCLEROTX FLUID COLLECTION
|
Facility
|
OP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
76102943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$392.60 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem Medicaid |
$1,038.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Humana KY Medicaid |
$1,038.58
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,049.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,059.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
SCLEROTX FLUID COLLECTION
|
Facility
|
IP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
76102943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$392.60 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$906.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
SCLEROTX FLUID COLLECTION
|
Professional
|
Both
|
$3,020.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
76102943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.97 |
| Max. Negotiated Rate |
$3,020.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.97
|
| Rate for Payer: Anthem Medicaid |
$100.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,020.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$205.83
|
| Rate for Payer: Humana Medicaid |
$100.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.75
|
| Rate for Payer: Molina Healthcare Passport |
$100.74
|
| Rate for Payer: Multiplan PHCS |
$1,812.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,114.00
|
| Rate for Payer: UHCCP Medicaid |
$104.97
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.75
|
|
|
SCLEROTX FLUID COLLECTION (P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
761P2943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.97 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.97
|
| Rate for Payer: Anthem Medicaid |
$100.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$205.83
|
| Rate for Payer: Humana Medicaid |
$100.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.75
|
| Rate for Payer: Molina Healthcare Passport |
$100.74
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$104.97
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.75
|
|
|
SCLEROTX FLUID COLLECTION (T
|
Facility
|
IP
|
$2,745.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
761T2943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$356.85 |
| Max. Negotiated Rate |
$2,635.20 |
| Rate for Payer: Aetna Commercial |
$2,113.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,141.10
|
| Rate for Payer: Cash Price |
$1,372.50
|
| Rate for Payer: Cigna Commercial |
$2,278.35
|
| Rate for Payer: First Health Commercial |
$2,607.75
|
| Rate for Payer: Humana Commercial |
$2,333.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,250.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,025.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$823.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,415.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,058.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$356.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$850.95
|
| Rate for Payer: PHCS Commercial |
$2,635.20
|
| Rate for Payer: United Healthcare All Payer |
$2,415.60
|
|
|
SCLEROTX FLUID COLLECTION (T
|
Facility
|
OP
|
$2,745.00
|
|
|
Service Code
|
HCPCS 49185
|
| Hospital Charge Code |
761T2943
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$356.85 |
| Max. Negotiated Rate |
$2,635.20 |
| Rate for Payer: Aetna Commercial |
$2,113.65
|
| Rate for Payer: Anthem Medicaid |
$944.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,141.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,372.50
|
| Rate for Payer: Cash Price |
$1,372.50
|
| Rate for Payer: Cigna Commercial |
$2,278.35
|
| Rate for Payer: First Health Commercial |
$2,607.75
|
| Rate for Payer: Humana Commercial |
$2,333.25
|
| Rate for Payer: Humana KY Medicaid |
$944.01
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$953.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,250.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,025.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$962.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,415.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,058.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$356.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$850.95
|
| Rate for Payer: PHCS Commercial |
$2,635.20
|
| Rate for Payer: United Healthcare All Payer |
$2,415.60
|
|
|
SCOPOLAMINE 2.5MG TABLET
|
Facility
|
IP
|
$9.35
|
|
|
Service Code
|
NDC 76385010001
|
| Hospital Charge Code |
25001374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.76
|
| Rate for Payer: First Health Commercial |
$8.88
|
| Rate for Payer: Humana Commercial |
$7.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.23
|
| Rate for Payer: Ohio Health Group HMO |
$7.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.98
|
| Rate for Payer: United Healthcare All Payer |
$8.23
|
|
|
SCOPOLAMINE 2.5MG TABLET
|
Facility
|
OP
|
$9.35
|
|
|
Service Code
|
NDC 76385010001
|
| Hospital Charge Code |
25001374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$8.98 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Anthem Medicaid |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.76
|
| Rate for Payer: First Health Commercial |
$8.88
|
| Rate for Payer: Humana Commercial |
$7.95
|
| Rate for Payer: Humana KY Medicaid |
$3.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.23
|
| Rate for Payer: Ohio Health Group HMO |
$7.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$8.98
|
| Rate for Payer: United Healthcare All Payer |
$8.23
|
|
|
SCOREFLEX NC SCORING 2.5 X 20
|
Facility
|
IP
|
$4,475.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$581.75 |
| Max. Negotiated Rate |
$4,296.00 |
| Rate for Payer: Aetna Commercial |
$3,445.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,490.50
|
| Rate for Payer: Cash Price |
$2,237.50
|
| Rate for Payer: Cigna Commercial |
$3,714.25
|
| Rate for Payer: First Health Commercial |
$4,251.25
|
| Rate for Payer: Humana Commercial |
$3,803.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,669.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,302.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,387.25
|
| Rate for Payer: PHCS Commercial |
$4,296.00
|
| Rate for Payer: United Healthcare All Payer |
$3,938.00
|
|
|
SCOREFLEX NC SCORING 2.5 X 20
|
Facility
|
OP
|
$4,475.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$581.75 |
| Max. Negotiated Rate |
$4,296.00 |
| Rate for Payer: Aetna Commercial |
$3,445.75
|
| Rate for Payer: Anthem Medicaid |
$1,538.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,490.50
|
| Rate for Payer: Cash Price |
$2,237.50
|
| Rate for Payer: Cigna Commercial |
$3,714.25
|
| Rate for Payer: First Health Commercial |
$4,251.25
|
| Rate for Payer: Humana Commercial |
$3,803.75
|
| Rate for Payer: Humana KY Medicaid |
$1,538.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,554.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,669.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,302.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,569.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,387.25
|
| Rate for Payer: PHCS Commercial |
$4,296.00
|
| Rate for Payer: United Healthcare All Payer |
$3,938.00
|
|
|
SCOREFLEX NC SCORING 4 X 20
|
Facility
|
IP
|
$4,475.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$581.75 |
| Max. Negotiated Rate |
$4,296.00 |
| Rate for Payer: Aetna Commercial |
$3,445.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,490.50
|
| Rate for Payer: Cash Price |
$2,237.50
|
| Rate for Payer: Cigna Commercial |
$3,714.25
|
| Rate for Payer: First Health Commercial |
$4,251.25
|
| Rate for Payer: Humana Commercial |
$3,803.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,669.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,302.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,387.25
|
| Rate for Payer: PHCS Commercial |
$4,296.00
|
| Rate for Payer: United Healthcare All Payer |
$3,938.00
|
|
