|
TC 99M EXAMETAZIME PER DOSE
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
34000069
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$235.04 |
| Max. Negotiated Rate |
$1,735.68 |
| Rate for Payer: Aetna Commercial |
$1,392.16
|
| Rate for Payer: Anthem Medicaid |
$621.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.24
|
| Rate for Payer: Cash Price |
$904.00
|
| Rate for Payer: Cigna Commercial |
$1,500.64
|
| Rate for Payer: First Health Commercial |
$1,717.60
|
| Rate for Payer: Humana Commercial |
$1,536.80
|
| Rate for Payer: Humana KY Medicaid |
$621.77
|
| Rate for Payer: Kentucky WC Medicaid |
$628.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,356.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.48
|
| Rate for Payer: PHCS Commercial |
$1,735.68
|
| Rate for Payer: United Healthcare All Payer |
$1,591.04
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
34000065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem Medicaid |
$41.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.38
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Humana KY Medicaid |
$41.61
|
| Rate for Payer: Kentucky WC Medicaid |
$42.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.51
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
340T0065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.38
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.51
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
34000065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.38
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.51
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
340T0065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$15.73 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem Medicaid |
$41.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.38
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Humana KY Medicaid |
$41.61
|
| Rate for Payer: Kentucky WC Medicaid |
$42.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.51
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
340T0054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.90 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
IP
|
$230.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
34000054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.90 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
34000054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.90 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem Medicaid |
$79.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Humana KY Medicaid |
$79.10
|
| Rate for Payer: Kentucky WC Medicaid |
$79.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
OP
|
$230.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
340T0054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.90 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$177.10
|
| Rate for Payer: Anthem Medicaid |
$79.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$179.40
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$190.90
|
| Rate for Payer: First Health Commercial |
$218.50
|
| Rate for Payer: Humana Commercial |
$195.50
|
| Rate for Payer: Humana KY Medicaid |
$79.10
|
| Rate for Payer: Kentucky WC Medicaid |
$79.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$188.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$202.40
|
| Rate for Payer: Ohio Health Group HMO |
$172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.30
|
| Rate for Payer: PHCS Commercial |
$220.80
|
| Rate for Payer: United Healthcare All Payer |
$202.40
|
|
|
TC-99M MERTIATIDE PER VIAL
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
34000066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
TC-99M MERTIATIDE PER VIAL
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
34000066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem Medicaid |
$178.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Humana KY Medicaid |
$178.48
|
| Rate for Payer: Kentucky WC Medicaid |
$180.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
TC-99M MERTIATIDE PER VIAL(T
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
340T0066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem Medicaid |
$178.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Humana KY Medicaid |
$178.48
|
| Rate for Payer: Kentucky WC Medicaid |
$180.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
TC-99M MERTIATIDE PER VIAL(T
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
340T0066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$67.47 |
| Max. Negotiated Rate |
$498.24 |
| Rate for Payer: Aetna Commercial |
$399.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.82
|
| Rate for Payer: Cash Price |
$259.50
|
| Rate for Payer: Cigna Commercial |
$430.77
|
| Rate for Payer: First Health Commercial |
$493.05
|
| Rate for Payer: Humana Commercial |
$441.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.72
|
| Rate for Payer: Ohio Health Group HMO |
$389.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.89
|
| Rate for Payer: PHCS Commercial |
$498.24
|
| Rate for Payer: United Healthcare All Payer |
$456.72
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$177.60 |
| Rate for Payer: Aetna Commercial |
$142.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.30
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$153.55
|
| Rate for Payer: First Health Commercial |
$175.75
|
| Rate for Payer: Humana Commercial |
$157.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.80
|
| Rate for Payer: Ohio Health Group HMO |
$138.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.35
|
| Rate for Payer: PHCS Commercial |
$177.60
|
| Rate for Payer: United Healthcare All Payer |
$162.80
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Professional
|
Both
|
$185.00
|
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$185.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$185.00
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Multiplan PHCS |
$111.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$129.50
|
| Rate for Payer: UHCCP Medicaid |
$64.75
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$177.60 |
| Rate for Payer: Aetna Commercial |
$142.45
|
| Rate for Payer: Anthem Medicaid |
$63.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.30
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$153.55
|
| Rate for Payer: First Health Commercial |
$175.75
|
| Rate for Payer: Humana Commercial |
$157.25
|
| Rate for Payer: Humana KY Medicaid |
$63.62
|
| Rate for Payer: Kentucky WC Medicaid |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.80
|
| Rate for Payer: Ohio Health Group HMO |
$138.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.35
|
| Rate for Payer: PHCS Commercial |
$177.60
|
| Rate for Payer: United Healthcare All Payer |
$162.80
|
|
|
TC 99M SULFUR COLLOIDPER DOS(T
|
Facility
|
IP
|
$185.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
340T0056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$177.60 |
| Rate for Payer: Aetna Commercial |
$142.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.30
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$153.55
|
| Rate for Payer: First Health Commercial |
$175.75
|
| Rate for Payer: Humana Commercial |
$157.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.80
|
| Rate for Payer: Ohio Health Group HMO |
$138.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.35
|
| Rate for Payer: PHCS Commercial |
$177.60
|
| Rate for Payer: United Healthcare All Payer |
$162.80
|
|
|
TC 99M SULFUR COLLOIDPER DOS(T
|
Facility
|
OP
|
$185.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
340T0056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$24.05 |
| Max. Negotiated Rate |
$177.60 |
| Rate for Payer: Aetna Commercial |
$142.45
|
| Rate for Payer: Anthem Medicaid |
$63.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.30
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$153.55
|
| Rate for Payer: First Health Commercial |
$175.75
|
| Rate for Payer: Humana Commercial |
$157.25
|
| Rate for Payer: Humana KY Medicaid |
$63.62
|
| Rate for Payer: Kentucky WC Medicaid |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.80
|
| Rate for Payer: Ohio Health Group HMO |
$138.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.35
|
| Rate for Payer: PHCS Commercial |
$177.60
|
| Rate for Payer: United Healthcare All Payer |
$162.80
|
|
|
TCAT INSJ/RPL PERM LDLS PM
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
HCPCS 33274
|
| Hospital Charge Code |
76102882
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.75 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.25
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
TCAT INSJ/RPL PERM LDLS PM
|
Professional
|
Both
|
$1,175.00
|
|
|
Service Code
|
HCPCS 33274
|
| Hospital Charge Code |
76102882
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$395.51 |
| Max. Negotiated Rate |
$1,175.00 |
| Rate for Payer: Anthem Medicaid |
$395.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,175.00
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$893.36
|
| Rate for Payer: Humana Medicaid |
$395.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$671.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$403.42
|
| Rate for Payer: Molina Healthcare Passport |
$395.51
|
| Rate for Payer: Multiplan PHCS |
$705.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$822.50
|
| Rate for Payer: UHCCP Medicaid |
$411.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$399.47
|
|
|
TCAT INSJ/RPL PERM LDLS PM
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
HCPCS 33274
|
| Hospital Charge Code |
76102882
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.75 |
| Max. Negotiated Rate |
$23,589.87 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem Medicaid |
$404.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,849.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,589.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,747.38
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Humana KY Medicaid |
$404.08
|
| Rate for Payer: Humana Medicare Advantage |
$16,849.91
|
| Rate for Payer: Kentucky WC Medicaid |
$408.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,219.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$412.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.25
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
TCD VASACTIVITY STDY W/INJ
|
Facility
|
IP
|
$1,103.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
32000300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$143.39 |
| Max. Negotiated Rate |
$1,058.88 |
| Rate for Payer: Aetna Commercial |
$849.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$860.34
|
| Rate for Payer: Cash Price |
$551.50
|
| Rate for Payer: Cigna Commercial |
$915.49
|
| Rate for Payer: First Health Commercial |
$1,047.85
|
| Rate for Payer: Humana Commercial |
$937.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$904.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$970.64
|
| Rate for Payer: Ohio Health Group HMO |
$827.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.93
|
| Rate for Payer: PHCS Commercial |
$1,058.88
|
| Rate for Payer: United Healthcare All Payer |
$970.64
|
|
|
TCD VASACTIVITY STDY W/INJ
|
Facility
|
OP
|
$1,103.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
32000300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,058.88 |
| Rate for Payer: Aetna Commercial |
$849.31
|
| Rate for Payer: Anthem Medicaid |
$379.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$860.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$551.50
|
| Rate for Payer: Cash Price |
$551.50
|
| Rate for Payer: Cigna Commercial |
$915.49
|
| Rate for Payer: First Health Commercial |
$1,047.85
|
| Rate for Payer: Humana Commercial |
$937.55
|
| Rate for Payer: Humana KY Medicaid |
$379.32
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$383.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$904.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$386.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$970.64
|
| Rate for Payer: Ohio Health Group HMO |
$827.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.93
|
| Rate for Payer: PHCS Commercial |
$1,058.88
|
| Rate for Payer: United Healthcare All Payer |
$970.64
|
|
|
TCD VASACTIVITY STDY W/INJ
|
Professional
|
Both
|
$1,103.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
32000300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.19 |
| Max. Negotiated Rate |
$1,103.00 |
| Rate for Payer: Aetna Commercial |
$239.03
|
| Rate for Payer: Anthem Medicaid |
$174.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,103.00
|
| Rate for Payer: Cash Price |
$551.50
|
| Rate for Payer: Cash Price |
$551.50
|
| Rate for Payer: Cigna Commercial |
$331.11
|
| Rate for Payer: Healthspan PPO |
$255.34
|
| Rate for Payer: Humana Medicaid |
$174.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.60
|
| Rate for Payer: Molina Healthcare Passport |
$174.12
|
| Rate for Payer: Multiplan PHCS |
$661.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$772.10
|
| Rate for Payer: UHCCP Medicaid |
$386.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.86
|
|
|
TCD VASACTIVITY STDY W/INJ(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
320P0300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$76.19 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$239.03
|
| Rate for Payer: Anthem Medicaid |
$174.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$331.11
|
| Rate for Payer: Healthspan PPO |
$255.34
|
| Rate for Payer: Humana Medicaid |
$174.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.60
|
| Rate for Payer: Molina Healthcare Passport |
$174.12
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$131.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.86
|
|
