|
TC 99M ARCITUMOMAB PER VIAL
|
Facility
|
IP
|
$2,054.00
|
|
|
Service Code
|
HCPCS A9568
|
| Hospital Charge Code |
34000068
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$616.20 |
| Max. Negotiated Rate |
$1,971.84 |
| Rate for Payer: Aetna Commercial |
$1,581.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,602.12
|
| Rate for Payer: Cash Price |
$1,027.00
|
| Rate for Payer: Cigna Commercial |
$1,704.82
|
| Rate for Payer: First Health Commercial |
$1,951.30
|
| Rate for Payer: Humana Commercial |
$1,745.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,684.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,515.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$616.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,807.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,540.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,643.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,786.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,417.26
|
| Rate for Payer: PHCS Commercial |
$1,971.84
|
| Rate for Payer: United Healthcare All Payer |
$1,807.52
|
|
|
Tc99M EXAMETAZIME
|
Facility
|
OP
|
$22.10
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
34000127
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$1,123.28 |
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Anthem Medicaid |
$7.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$802.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,123.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,083.16
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cigna Commercial |
$18.34
|
| Rate for Payer: First Health Commercial |
$21.00
|
| Rate for Payer: Humana Commercial |
$18.79
|
| Rate for Payer: Humana KY Medicaid |
$7.60
|
| Rate for Payer: Humana Medicare Advantage |
$802.34
|
| Rate for Payer: Kentucky WC Medicaid |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$962.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.45
|
| Rate for Payer: Ohio Health Group HMO |
$16.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.25
|
| Rate for Payer: PHCS Commercial |
$21.22
|
| Rate for Payer: United Healthcare All Payer |
$19.45
|
|
|
Tc99M EXAMETAZIME
|
Professional
|
Both
|
$22.10
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
34000127
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$954.95 |
| Rate for Payer: Aetna Commercial |
$954.95
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.14
|
| Rate for Payer: Multiplan PHCS |
$13.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15.47
|
| Rate for Payer: UHCCP Medicaid |
$7.74
|
|
|
Tc99M EXAMETAZIME
|
Facility
|
IP
|
$22.10
|
|
|
Service Code
|
HCPCS A9521
|
| Hospital Charge Code |
34000127
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$21.22 |
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.24
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cigna Commercial |
$18.34
|
| Rate for Payer: First Health Commercial |
$21.00
|
| Rate for Payer: Humana Commercial |
$18.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.45
|
| Rate for Payer: Ohio Health Group HMO |
$16.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.25
|
| Rate for Payer: PHCS Commercial |
$21.22
|
| Rate for Payer: United Healthcare All Payer |
$19.45
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
34000065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$42.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Humana KY Medicaid |
$42.64
|
| Rate for Payer: Kentucky WC Medicaid |
$43.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Professional
|
Both
|
$124.00
|
|
| Hospital Charge Code |
34000065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$86.80 |
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Multiplan PHCS |
$74.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$86.80
|
| Rate for Payer: UHCCP Medicaid |
$43.40
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
34000065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
340T0065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$42.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Humana KY Medicaid |
$42.64
|
| Rate for Payer: Kentucky WC Medicaid |
$43.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
TC99M LABELED RBCS UP TO 30MCI
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS A9560
|
| Hospital Charge Code |
340T0065
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$96.72
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
340T0054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
340T0054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem Medicaid |
$84.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Humana KY Medicaid |
$84.26
|
| Rate for Payer: Kentucky WC Medicaid |
$85.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
34000054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem Medicaid |
$84.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Humana KY Medicaid |
$84.26
|
| Rate for Payer: Kentucky WC Medicaid |
$85.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
34000054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.05
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
TC 99M MEBROFENIN UP TO 15 MCI
|
Professional
|
Both
|
$245.00
|
|
| Hospital Charge Code |
34000054
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$171.50 |
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$85.75
|
|
|
TC-99M MERTIATIDE PER VIAL
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
34000066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$160.20 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
TC-99M MERTIATIDE PER VIAL
|
Professional
|
Both
|
$534.00
|
|
| Hospital Charge Code |
34000066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$186.90 |
| Max. Negotiated Rate |
$373.80 |
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Multiplan PHCS |
$320.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$373.80
|
| Rate for Payer: UHCCP Medicaid |
$186.90
|
|
|
TC-99M MERTIATIDE PER VIAL
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
34000066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$160.20 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem Medicaid |
$183.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Humana KY Medicaid |
$183.64
|
| Rate for Payer: Kentucky WC Medicaid |
$185.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
TC-99M MERTIATIDE PER VIAL(T
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
340T0066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$160.20 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem Medicaid |
$183.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Humana KY Medicaid |
$183.64
|
| Rate for Payer: Kentucky WC Medicaid |
$185.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
TC-99M MERTIATIDE PER VIAL(T
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
340T0066
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$160.20 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$464.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.46
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
TC-99M PER DOSE
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
34000069
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$621.77 |
| 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 Medicare Advantage/PPO |
$1,040.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,456.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,404.43
|
| Rate for Payer: Cash Price |
$904.00
|
| 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: Humana Medicare Advantage |
$1,040.32
|
| 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 |
$1,248.38
|
| 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 |
$1,446.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.52
|
| Rate for Payer: PHCS Commercial |
$1,735.68
|
| Rate for Payer: United Healthcare All Payer |
$1,591.04
|
|
|
TC-99M PER DOSE
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS A9569
|
| Hospital Charge Code |
34000069
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$542.40 |
| Max. Negotiated Rate |
$1,735.68 |
| Rate for Payer: Aetna Commercial |
$1,392.16
|
| 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: 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: 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 |
$1,446.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.52
|
| Rate for Payer: PHCS Commercial |
$1,735.68
|
| Rate for Payer: United Healthcare All Payer |
$1,591.04
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem Medicaid |
$67.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Humana KY Medicaid |
$67.40
|
| Rate for Payer: Kentucky WC Medicaid |
$68.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.24
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Professional
|
Both
|
$196.00
|
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$137.20 |
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Multiplan PHCS |
$117.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$137.20
|
| Rate for Payer: UHCCP Medicaid |
$68.60
|
|
|
TC 99M SULFUR COLLOIDPER DOSE
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
34000056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.24
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
TC 99M SULFUR COLLOIDPER DOS(T
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
340T0056
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem Medicaid |
$67.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Humana KY Medicaid |
$67.40
|
| Rate for Payer: Kentucky WC Medicaid |
$68.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.24
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
