|
TRUXIMA 10mg (100mg Vial)
|
Facility
|
IP
|
$4,608.25
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25003880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,382.47 |
| Max. Negotiated Rate |
$4,423.92 |
| Rate for Payer: Aetna Commercial |
$3,548.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,594.43
|
| Rate for Payer: Cash Price |
$2,304.12
|
| Rate for Payer: Cigna Commercial |
$3,824.85
|
| Rate for Payer: First Health Commercial |
$4,377.84
|
| Rate for Payer: Humana Commercial |
$3,917.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,778.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,400.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,055.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,686.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,009.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,179.69
|
| Rate for Payer: PHCS Commercial |
$4,423.92
|
| Rate for Payer: United Healthcare All Payer |
$4,055.26
|
|
|
TRUXIMA 10mg (500mg Vial)
|
Facility
|
OP
|
$23,041.24
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25003881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.18 |
| Max. Negotiated Rate |
$22,119.59 |
| Rate for Payer: Aetna Commercial |
$17,741.75
|
| Rate for Payer: Anthem Medicaid |
$7,923.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$31.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,972.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$43.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.09
|
| Rate for Payer: Cash Price |
$11,520.62
|
| Rate for Payer: Cash Price |
$11,520.62
|
| Rate for Payer: Cigna Commercial |
$19,124.23
|
| Rate for Payer: First Health Commercial |
$21,889.18
|
| Rate for Payer: Humana Commercial |
$19,585.05
|
| Rate for Payer: Humana KY Medicaid |
$7,923.88
|
| Rate for Payer: Humana Medicare Advantage |
$31.18
|
| Rate for Payer: Kentucky WC Medicaid |
$8,004.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,893.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,004.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,082.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,276.29
|
| Rate for Payer: Ohio Health Group HMO |
$17,280.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,432.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,045.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,898.46
|
| Rate for Payer: PHCS Commercial |
$22,119.59
|
| Rate for Payer: United Healthcare All Payer |
$20,276.29
|
|
|
TRUXIMA 10mg (500mg Vial)
|
Facility
|
IP
|
$23,041.24
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25003881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,912.37 |
| Max. Negotiated Rate |
$22,119.59 |
| Rate for Payer: Aetna Commercial |
$17,741.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,972.17
|
| Rate for Payer: Cash Price |
$11,520.62
|
| Rate for Payer: Cigna Commercial |
$19,124.23
|
| Rate for Payer: First Health Commercial |
$21,889.18
|
| Rate for Payer: Humana Commercial |
$19,585.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,893.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,004.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,912.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,276.29
|
| Rate for Payer: Ohio Health Group HMO |
$17,280.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,432.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,045.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,898.46
|
| Rate for Payer: PHCS Commercial |
$22,119.59
|
| Rate for Payer: United Healthcare All Payer |
$20,276.29
|
|
|
TRY ME KIT - ACNE
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
22200137
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem Medicaid |
$6.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Humana KY Medicaid |
$6.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TRY ME KIT - ACNE
|
Professional
|
Both
|
$20.00
|
|
| Hospital Charge Code |
22200137
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Multiplan PHCS |
$12.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.00
|
| Rate for Payer: UHCCP Medicaid |
$7.00
|
|
|
TRY ME KIT - ACNE
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
22200137
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TRY ME KIT - AGING
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
22200135
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TRY ME KIT - AGING
|
Professional
|
Both
|
$20.00
|
|
| Hospital Charge Code |
22200135
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Multiplan PHCS |
$12.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.00
|
| Rate for Payer: UHCCP Medicaid |
$7.00
|
|
|
TRY ME KIT - AGING
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
22200135
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem Medicaid |
$6.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Humana KY Medicaid |
$6.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TRY ME KIT - SENSITIVE
|
Facility
|
IP
|
$20.00
|
|
| Hospital Charge Code |
22200136
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TRY ME KIT - SENSITIVE
|
Professional
|
Both
|
$20.00
|
|
| Hospital Charge Code |
22200136
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Multiplan PHCS |
$12.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.00
|
| Rate for Payer: UHCCP Medicaid |
$7.00
|
|
|
TRY ME KIT - SENSITIVE
|
Facility
|
OP
|
$20.00
|
|
| Hospital Charge Code |
22200136
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$19.20 |
| Rate for Payer: Aetna Commercial |
$15.40
|
| Rate for Payer: Anthem Medicaid |
$6.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15.60
|
| Rate for Payer: Cash Price |
$10.00
|
| Rate for Payer: Cigna Commercial |
$16.60
|
| Rate for Payer: First Health Commercial |
$19.00
|
| Rate for Payer: Humana Commercial |
$17.00
|
| Rate for Payer: Humana KY Medicaid |
$6.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$17.60
|
| Rate for Payer: Ohio Health Group HMO |
$15.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.80
|
| Rate for Payer: PHCS Commercial |
$19.20
|
| Rate for Payer: United Healthcare All Payer |
$17.60
|
|
|
TTE W W/O FOL W/CON STRESS
|
Professional
|
Both
|
$2,832.00
|
|
|
Service Code
|
HCPCS 93350
|
| Hospital Charge Code |
48300014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$100.67 |
| Max. Negotiated Rate |
$1,699.20 |
| Rate for Payer: Aetna Commercial |
$339.66
|
| Rate for Payer: Ambetter Exchange |
$165.63
|
| Rate for Payer: Anthem Medicaid |
$126.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$165.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$165.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$198.76
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cigna Commercial |
$266.92
|
| Rate for Payer: Healthspan PPO |
$319.29
|
| Rate for Payer: Humana Medicaid |
$126.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$165.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.60
|
| Rate for Payer: Molina Healthcare Passport |
$126.08
|
| Rate for Payer: Multiplan PHCS |
$1,699.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$215.32
|
| Rate for Payer: UHCCP Medicaid |
$991.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$127.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$165.63
|
|
|
TTE W W/O FOL W/CON STRESS
|
Facility
|
IP
|
$2,832.00
|
|
|
Service Code
|
HCPCS C8928
|
| Hospital Charge Code |
48300014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$849.60 |
| Max. Negotiated Rate |
$2,718.72 |
| Rate for Payer: Aetna Commercial |
$2,180.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,208.96
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cigna Commercial |
$2,350.56
|
| Rate for Payer: First Health Commercial |
$2,690.40
|
| Rate for Payer: Humana Commercial |
$2,407.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,322.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,090.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$849.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,492.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,124.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,265.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,463.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,954.08
|
| Rate for Payer: PHCS Commercial |
$2,718.72
|
| Rate for Payer: United Healthcare All Payer |
$2,492.16
|
|
|
TTE W W/O FOL W/CON STRESS
|
Facility
|
OP
|
$2,832.00
|
|
|
Service Code
|
HCPCS C8928
|
| Hospital Charge Code |
48300014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,718.72 |
| Rate for Payer: Aetna Commercial |
$2,180.64
|
| Rate for Payer: Anthem Medicaid |
$973.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,208.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cash Price |
$1,416.00
|
| Rate for Payer: Cigna Commercial |
$2,350.56
|
| Rate for Payer: First Health Commercial |
$2,690.40
|
| Rate for Payer: Humana Commercial |
$2,407.20
|
| Rate for Payer: Humana KY Medicaid |
$973.92
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$983.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,322.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,090.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$993.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,492.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,124.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,265.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,463.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,954.08
|
| Rate for Payer: PHCS Commercial |
$2,718.72
|
| Rate for Payer: United Healthcare All Payer |
$2,492.16
|
|
|
TTE W W/O FOL W/CON STRESS (P
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
HCPCS 93350
|
| Hospital Charge Code |
483P0014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$339.66 |
| Rate for Payer: Aetna Commercial |
$339.66
|
| Rate for Payer: Ambetter Exchange |
$165.63
|
| Rate for Payer: Anthem Medicaid |
$126.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$165.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$165.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$198.76
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$266.92
|
| Rate for Payer: Healthspan PPO |
$319.29
|
| Rate for Payer: Humana Medicaid |
$126.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$165.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.60
|
| Rate for Payer: Molina Healthcare Passport |
$126.08
|
| Rate for Payer: Multiplan PHCS |
$162.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$215.32
|
| Rate for Payer: UHCCP Medicaid |
$94.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$127.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$165.63
|
|
|
TTE W W/O FOL W/CON STRESS (T
|
Facility
|
OP
|
$2,562.00
|
|
|
Service Code
|
HCPCS C8928
|
| Hospital Charge Code |
483T0014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,459.52 |
| Rate for Payer: Aetna Commercial |
$1,972.74
|
| Rate for Payer: Anthem Medicaid |
$881.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,998.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,281.00
|
| Rate for Payer: Cash Price |
$1,281.00
|
| Rate for Payer: Cigna Commercial |
$2,126.46
|
| Rate for Payer: First Health Commercial |
$2,433.90
|
| Rate for Payer: Humana Commercial |
$2,177.70
|
| Rate for Payer: Humana KY Medicaid |
$881.07
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$890.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,100.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,890.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$898.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,254.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,921.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,049.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,228.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,767.78
|
| Rate for Payer: PHCS Commercial |
$2,459.52
|
| Rate for Payer: United Healthcare All Payer |
$2,254.56
|
|
|
TTE W W/O FOL W/CON STRESS (T
|
Facility
|
IP
|
$2,562.00
|
|
|
Service Code
|
HCPCS C8928
|
| Hospital Charge Code |
483T0014
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$768.60 |
| Max. Negotiated Rate |
$2,459.52 |
| Rate for Payer: Aetna Commercial |
$1,972.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,998.36
|
| Rate for Payer: Cash Price |
$1,281.00
|
| Rate for Payer: Cigna Commercial |
$2,126.46
|
| Rate for Payer: First Health Commercial |
$2,433.90
|
| Rate for Payer: Humana Commercial |
$2,177.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,100.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,890.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$768.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,254.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,921.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,049.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,228.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,767.78
|
| Rate for Payer: PHCS Commercial |
$2,459.52
|
| Rate for Payer: United Healthcare All Payer |
$2,254.56
|
|
|
TUBAL AT TIME OF C-SECTION
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 58611
|
| Hospital Charge Code |
76102246
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
TUBAL AT TIME OF C-SECTION
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 58611
|
| Hospital Charge Code |
76102246
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.52 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$121.13
|
| Rate for Payer: Ambetter Exchange |
$71.42
|
| Rate for Payer: Anthem Medicaid |
$33.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$71.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$71.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.70
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$119.21
|
| Rate for Payer: Healthspan PPO |
$117.29
|
| Rate for Payer: Humana Medicaid |
$33.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$71.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.19
|
| Rate for Payer: Molina Healthcare Passport |
$33.52
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$92.85
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$71.42
|
|
|
TUBAL AT TIME OF C-SECTION
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 58611
|
| Hospital Charge Code |
76102246
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
TUBAL AT TIME OF C-SECTION(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 58611
|
| Hospital Charge Code |
761P2246
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.52 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$121.13
|
| Rate for Payer: Ambetter Exchange |
$71.42
|
| Rate for Payer: Anthem Medicaid |
$33.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$71.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$71.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.70
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$119.21
|
| Rate for Payer: Healthspan PPO |
$117.29
|
| Rate for Payer: Humana Medicaid |
$33.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$71.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.19
|
| Rate for Payer: Molina Healthcare Passport |
$33.52
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$92.85
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$71.42
|
|
|
TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,009.49
|
|
|
Service Code
|
CPT 32551
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,435.35 |
| Max. Negotiated Rate |
$2,009.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,435.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,009.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,937.72
|
| Rate for Payer: Humana Medicare Advantage |
$1,435.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,722.42
|
|
|
TUBOPLASTY
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58760
|
| Hospital Charge Code |
76102259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
TUBOPLASTY
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58760
|
| Hospital Charge Code |
76102259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$776.85 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,255.23
|
| Rate for Payer: Ambetter Exchange |
$776.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$776.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$776.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$932.22
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,223.89
|
| Rate for Payer: Healthspan PPO |
$1,215.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,056.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$776.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$776.85
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,009.90
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$776.85
|
|
