|
SPIROFLEX ULTRA
|
Facility
|
OP
|
$9,114.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,184.88 |
| Max. Negotiated Rate |
$8,749.92 |
| Rate for Payer: Aetna Commercial |
$7,018.16
|
| Rate for Payer: Anthem Medicaid |
$3,134.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,109.31
|
| Rate for Payer: Cash Price |
$4,557.25
|
| Rate for Payer: Cigna Commercial |
$7,565.04
|
| Rate for Payer: First Health Commercial |
$8,658.78
|
| Rate for Payer: Humana Commercial |
$7,747.32
|
| Rate for Payer: Humana KY Medicaid |
$3,134.48
|
| Rate for Payer: Kentucky WC Medicaid |
$3,166.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,473.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,726.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,734.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,197.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,020.76
|
| Rate for Payer: Ohio Health Group HMO |
$6,835.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,822.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,184.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,825.50
|
| Rate for Payer: PHCS Commercial |
$8,749.92
|
| Rate for Payer: United Healthcare All Payer |
$8,020.76
|
|
|
SPIROMETRY PRE/POST
|
Professional
|
Both
|
$577.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
46000002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$577.00 |
| Rate for Payer: Aetna Commercial |
$88.17
|
| Rate for Payer: Anthem Medicaid |
$45.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$577.00
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$82.82
|
| Rate for Payer: Healthspan PPO |
$68.30
|
| Rate for Payer: Humana Medicaid |
$45.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$46.26
|
| Rate for Payer: Molina Healthcare Passport |
$45.35
|
| Rate for Payer: Multiplan PHCS |
$346.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$403.90
|
| Rate for Payer: UHCCP Medicaid |
$201.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.80
|
|
|
SPIROMETRY PRE/POST
|
Facility
|
IP
|
$577.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
46000002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$75.01 |
| Max. Negotiated Rate |
$553.92 |
| Rate for Payer: Aetna Commercial |
$444.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.06
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$478.91
|
| Rate for Payer: First Health Commercial |
$548.15
|
| Rate for Payer: Humana Commercial |
$490.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.76
|
| Rate for Payer: Ohio Health Group HMO |
$432.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.87
|
| Rate for Payer: PHCS Commercial |
$553.92
|
| Rate for Payer: United Healthcare All Payer |
$507.76
|
|
|
SPIROMETRY PRE/POST
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
46000002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$75.01 |
| Max. Negotiated Rate |
$553.92 |
| Rate for Payer: Aetna Commercial |
$444.29
|
| Rate for Payer: Anthem Medicaid |
$198.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cash Price |
$288.50
|
| Rate for Payer: Cigna Commercial |
$478.91
|
| Rate for Payer: First Health Commercial |
$548.15
|
| Rate for Payer: Humana Commercial |
$490.45
|
| Rate for Payer: Humana KY Medicaid |
$198.43
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$200.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.76
|
| Rate for Payer: Ohio Health Group HMO |
$432.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.87
|
| Rate for Payer: PHCS Commercial |
$553.92
|
| Rate for Payer: United Healthcare All Payer |
$507.76
|
|
|
SPIROMETRY PRE/POST(P
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
460P0002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$88.17 |
| Rate for Payer: Aetna Commercial |
$88.17
|
| Rate for Payer: Anthem Medicaid |
$45.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$53.00
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$82.82
|
| Rate for Payer: Healthspan PPO |
$68.30
|
| Rate for Payer: Humana Medicaid |
$45.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$46.26
|
| Rate for Payer: Molina Healthcare Passport |
$45.35
|
| Rate for Payer: Multiplan PHCS |
$31.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.10
|
| Rate for Payer: UHCCP Medicaid |
$18.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.80
|
|
|
SPIROMETRY PRE/POST(T
|
Facility
|
OP
|
$524.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
460T0002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$68.12 |
| Max. Negotiated Rate |
$503.04 |
| Rate for Payer: Aetna Commercial |
$403.48
|
| Rate for Payer: Anthem Medicaid |
$180.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cigna Commercial |
$434.92
|
| Rate for Payer: First Health Commercial |
$497.80
|
| Rate for Payer: Humana Commercial |
$445.40
|
| Rate for Payer: Humana KY Medicaid |
$180.20
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$429.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$183.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$461.12
|
| Rate for Payer: Ohio Health Group HMO |
$393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.44
|
| Rate for Payer: PHCS Commercial |
$503.04
|
| Rate for Payer: United Healthcare All Payer |
$461.12
|
|
|
SPIROMETRY PRE/POST(T
|
Facility
|
IP
|
$524.00
|
|
|
Service Code
|
HCPCS 94060
|
| Hospital Charge Code |
460T0002
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$68.12 |
| Max. Negotiated Rate |
$503.04 |
| Rate for Payer: Aetna Commercial |
$403.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.72
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cigna Commercial |
$434.92
|
| Rate for Payer: First Health Commercial |
$497.80
|
| Rate for Payer: Humana Commercial |
$445.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$429.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$157.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$461.12
|
| Rate for Payer: Ohio Health Group HMO |
$393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.44
|
| Rate for Payer: PHCS Commercial |
$503.04
|
| Rate for Payer: United Healthcare All Payer |
$461.12
|
|
|
SPIRONOLACTONE 100MG TABLET
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 59746021801
|
| Hospital Charge Code |
25003481
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
SPIRONOLACTONE 100MG TABLET
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 59746021801
|
| Hospital Charge Code |
25003481
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
SP KNOX BILAT CATARACT SX (P)
|
Professional
|
Both
|
$6,700.00
|
|
| Hospital Charge Code |
36001279
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$2,345.00 |
| Max. Negotiated Rate |
$6,700.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$6,700.00
|
| Rate for Payer: Cash Price |
$3,350.00
|
| Rate for Payer: Multiplan PHCS |
$4,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,690.00
|
| Rate for Payer: UHCCP Medicaid |
$2,345.00
|
|
|
SP KNOX BILAT CATARACT SX (S)
|
Professional
|
Both
|
$5,100.00
|
|
| Hospital Charge Code |
36001281
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1,785.00 |
| Max. Negotiated Rate |
$5,100.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$5,100.00
|
| Rate for Payer: Cash Price |
$2,550.00
|
| Rate for Payer: Multiplan PHCS |
$3,060.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,570.00
|
| Rate for Payer: UHCCP Medicaid |
$1,785.00
|
|
|
SP KNOX BILAT CATARACT SX (T)
|
Professional
|
Both
|
$5,700.00
|
|
| Hospital Charge Code |
36001280
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$5,700.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$5,700.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Multiplan PHCS |
$3,420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,990.00
|
| Rate for Payer: UHCCP Medicaid |
$1,995.00
|
|
|
SP KNOX UNILAT CATARACT SX (P)
|
Professional
|
Both
|
$4,800.00
|
|
| Hospital Charge Code |
36001282
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1,680.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,800.00
|
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Multiplan PHCS |
$2,880.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,360.00
|
| Rate for Payer: UHCCP Medicaid |
$1,680.00
|
|
|
SP KNOX UNILAT CATARACT SX (S)
|
Professional
|
Both
|
$4,000.00
|
|
| Hospital Charge Code |
36001284
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1,400.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,800.00
|
| Rate for Payer: UHCCP Medicaid |
$1,400.00
|
|
|
SP KNOX UNILAT CATARACT SX (T)
|
Professional
|
Both
|
$4,300.00
|
|
| Hospital Charge Code |
36001283
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1,505.00 |
| Max. Negotiated Rate |
$4,300.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,300.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Multiplan PHCS |
$2,580.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,010.00
|
| Rate for Payer: UHCCP Medicaid |
$1,505.00
|
|
|
SPLEEN ULTRASOUND ONLY LTD
|
Professional
|
Both
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,104.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$662.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$772.80
|
| Rate for Payer: UHCCP Medicaid |
$386.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
SPLEEN ULTRASOUND ONLY LTD
|
Facility
|
OP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem Medicaid |
$379.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Humana KY Medicaid |
$379.67
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$383.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
SPLEEN ULTRASOUND ONLY LTD
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$143.52 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
SPLEEN ULTRASOUND ONLY LTD(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
SPLEEN ULTRASOUND ONLY LTD(T
|
Facility
|
OP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem Medicaid |
$336.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Humana KY Medicaid |
$336.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$340.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
SPLEEN ULTRASOUND ONLY LTD(T
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0021
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
SPLENECTOMY; TOTAL (SEPARATE P
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 38100
|
| Hospital Charge Code |
76101585
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
SPLENECTOMY; TOTAL (SEPARATE P
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 38100
|
| Hospital Charge Code |
76101585
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
SPLENECTOMY; TOTAL (SEPARATE P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 38100
|
| Hospital Charge Code |
761P1585
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$625.14 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$1,631.60
|
| Rate for Payer: Anthem Medicaid |
$625.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,492.74
|
| Rate for Payer: Healthspan PPO |
$1,304.61
|
| Rate for Payer: Humana Medicaid |
$625.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,466.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$637.64
|
| Rate for Payer: Molina Healthcare Passport |
$625.14
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$631.39
|
|
|
SPLENECTOMY; TOTAL (SEPARATE P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 38100
|
| Hospital Charge Code |
76101585
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$625.14 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$1,631.60
|
| Rate for Payer: Anthem Medicaid |
$625.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,492.74
|
| Rate for Payer: Healthspan PPO |
$1,304.61
|
| Rate for Payer: Humana Medicaid |
$625.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,466.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$637.64
|
| Rate for Payer: Molina Healthcare Passport |
$625.14
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$631.39
|
|
