|
TUBOPLASTY
|
Facility
|
IP
|
$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 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: 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: 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(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58760
|
| Hospital Charge Code |
761P2259
|
|
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
|
|
|
TUBOUTERINE IMPLANTATION
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58752
|
| Hospital Charge Code |
76102258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
TUBOUTERINE IMPLANTATION
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58752
|
| Hospital Charge Code |
76102258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
TUBOUTERINE IMPLANTATION
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58752
|
| Hospital Charge Code |
76102258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$805.00 |
| Max. Negotiated Rate |
$1,390.54 |
| Rate for Payer: Aetna Commercial |
$1,390.54
|
| Rate for Payer: Ambetter Exchange |
$859.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$859.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$859.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,031.50
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,332.43
|
| Rate for Payer: Healthspan PPO |
$1,346.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,094.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$859.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$859.58
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,117.45
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$859.58
|
|
|
TUBOUTERINE IMPLANTATION(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58752
|
| Hospital Charge Code |
761P2258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$805.00 |
| Max. Negotiated Rate |
$1,390.54 |
| Rate for Payer: Aetna Commercial |
$1,390.54
|
| Rate for Payer: Ambetter Exchange |
$859.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$859.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$859.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,031.50
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,332.43
|
| Rate for Payer: Healthspan PPO |
$1,346.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,094.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$859.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$859.58
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,117.45
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$859.58
|
|
|
TUCKS WIPES 40 COUNT
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
25001607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.06
|
| Rate for Payer: First Health Commercial |
$0.07
|
| Rate for Payer: Humana Commercial |
$0.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.06
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.05
|
| Rate for Payer: PHCS Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Payer |
$0.06
|
|
|
TUCKS WIPES 40 COUNT
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
25001607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.06
|
| Rate for Payer: First Health Commercial |
$0.07
|
| Rate for Payer: Humana Commercial |
$0.06
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.06
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.05
|
| Rate for Payer: PHCS Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Payer |
$0.06
|
|
|
TUMOR IMAGING LIMITED AREA
|
Facility
|
OP
|
$2,212.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
34000033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$2,123.52 |
| Rate for Payer: Aetna Commercial |
$1,703.24
|
| Rate for Payer: Anthem Medicaid |
$760.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cigna Commercial |
$1,835.96
|
| Rate for Payer: First Health Commercial |
$2,101.40
|
| Rate for Payer: Humana Commercial |
$1,880.20
|
| Rate for Payer: Humana KY Medicaid |
$760.71
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$768.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$775.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.28
|
| Rate for Payer: PHCS Commercial |
$2,123.52
|
| Rate for Payer: United Healthcare All Payer |
$1,946.56
|
|
|
TUMOR IMAGING LIMITED AREA
|
Facility
|
IP
|
$2,212.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
34000033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$663.60 |
| Max. Negotiated Rate |
$2,123.52 |
| Rate for Payer: Aetna Commercial |
$1,703.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.36
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cigna Commercial |
$1,835.96
|
| Rate for Payer: First Health Commercial |
$2,101.40
|
| Rate for Payer: Humana Commercial |
$1,880.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.28
|
| Rate for Payer: PHCS Commercial |
$2,123.52
|
| Rate for Payer: United Healthcare All Payer |
$1,946.56
|
|
|
TUMOR IMAGING LIMITED AREA
|
Professional
|
Both
|
$2,212.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
34000033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$36.97 |
| Max. Negotiated Rate |
$1,327.20 |
| Rate for Payer: Aetna Commercial |
$274.80
|
| Rate for Payer: Ambetter Exchange |
$203.76
|
| Rate for Payer: Anthem Medicaid |
$193.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$203.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$203.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.51
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Healthspan PPO |
$274.66
|
| Rate for Payer: Humana Medicaid |
$193.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$203.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$203.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$197.83
|
| Rate for Payer: Molina Healthcare Passport |
$193.95
|
| Rate for Payer: Multiplan PHCS |
$1,327.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$264.89
|
| Rate for Payer: UHCCP Medicaid |
$774.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$195.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$203.76
|
|
|
TUMOR IMAGING LIMITED AREA(P
|
Professional
|
Both
|
$598.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
340P0033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$36.97 |
| Max. Negotiated Rate |
$358.80 |
| Rate for Payer: Aetna Commercial |
$274.80
|
| Rate for Payer: Ambetter Exchange |
$203.76
|
| Rate for Payer: Anthem Medicaid |
$193.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$203.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$203.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.51
|
| Rate for Payer: Cash Price |
$299.00
|
| Rate for Payer: Cash Price |
$299.00
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Healthspan PPO |
$274.66
|
| Rate for Payer: Humana Medicaid |
$193.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$203.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$203.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$197.83
|
| Rate for Payer: Molina Healthcare Passport |
$193.95
|
| Rate for Payer: Multiplan PHCS |
$358.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$264.89
|
| Rate for Payer: UHCCP Medicaid |
$209.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$195.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$203.76
|
|
|
TUMOR IMAGING LIMITED AREA(T
|
Facility
|
OP
|
$1,614.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
340T0033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,549.44 |
| Rate for Payer: Aetna Commercial |
$1,242.78
|
| Rate for Payer: Anthem Medicaid |
$555.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,258.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$807.00
|
| Rate for Payer: Cash Price |
$807.00
|
| Rate for Payer: Cigna Commercial |
$1,339.62
|
| Rate for Payer: First Health Commercial |
$1,533.30
|
| Rate for Payer: Humana Commercial |
$1,371.90
|
| Rate for Payer: Humana KY Medicaid |
$555.05
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$560.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,323.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,191.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$566.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,420.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,210.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,291.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,404.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,113.66
|
| Rate for Payer: PHCS Commercial |
$1,549.44
|
| Rate for Payer: United Healthcare All Payer |
$1,420.32
|
|
|
TUMOR IMAGING LIMITED AREA(T
|
Facility
|
IP
|
$1,614.00
|
|
|
Service Code
|
HCPCS 78800
|
| Hospital Charge Code |
340T0033
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$484.20 |
| Max. Negotiated Rate |
$1,549.44 |
| Rate for Payer: Aetna Commercial |
$1,242.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,258.92
|
| Rate for Payer: Cash Price |
$807.00
|
| Rate for Payer: Cigna Commercial |
$1,339.62
|
| Rate for Payer: First Health Commercial |
$1,533.30
|
| Rate for Payer: Humana Commercial |
$1,371.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,323.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,191.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$484.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,420.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,210.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,291.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,404.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,113.66
|
| Rate for Payer: PHCS Commercial |
$1,549.44
|
| Rate for Payer: United Healthcare All Payer |
$1,420.32
|
|
|
TUMOR IMAGING WHOLE BODY
|
Professional
|
Both
|
$1,982.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
34000037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$59.16 |
| Max. Negotiated Rate |
$1,189.20 |
| Rate for Payer: Aetna Commercial |
$833.66
|
| Rate for Payer: Ambetter Exchange |
$506.98
|
| Rate for Payer: Anthem Medicaid |
$492.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$506.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$506.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$608.38
|
| Rate for Payer: Cash Price |
$991.00
|
| Rate for Payer: Cash Price |
$991.00
|
| Rate for Payer: Cigna Commercial |
$742.07
|
| Rate for Payer: Healthspan PPO |
$833.23
|
| Rate for Payer: Humana Medicaid |
$492.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$506.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$506.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$502.47
|
| Rate for Payer: Molina Healthcare Passport |
$492.62
|
| Rate for Payer: Multiplan PHCS |
$1,189.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$659.07
|
| Rate for Payer: UHCCP Medicaid |
$693.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$497.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$506.98
|
|
|
TUMOR IMAGING WHOLE BODY
|
Facility
|
OP
|
$1,982.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
34000037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$681.61 |
| Max. Negotiated Rate |
$1,902.72 |
| Rate for Payer: Aetna Commercial |
$1,526.14
|
| Rate for Payer: Anthem Medicaid |
$681.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,206.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,545.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,688.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,628.42
|
| Rate for Payer: Cash Price |
$991.00
|
| Rate for Payer: Cash Price |
$991.00
|
| Rate for Payer: Cigna Commercial |
$1,645.06
|
| Rate for Payer: First Health Commercial |
$1,882.90
|
| Rate for Payer: Humana Commercial |
$1,684.70
|
| Rate for Payer: Humana KY Medicaid |
$681.61
|
| Rate for Payer: Humana Medicare Advantage |
$1,206.24
|
| Rate for Payer: Kentucky WC Medicaid |
$688.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,625.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,462.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$695.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,744.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,486.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,585.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,724.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,367.58
|
| Rate for Payer: PHCS Commercial |
$1,902.72
|
| Rate for Payer: United Healthcare All Payer |
$1,744.16
|
|
|
TUMOR IMAGING WHOLE BODY
|
Facility
|
IP
|
$1,982.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
34000037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$594.60 |
| Max. Negotiated Rate |
$1,902.72 |
| Rate for Payer: Aetna Commercial |
$1,526.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,545.96
|
| Rate for Payer: Cash Price |
$991.00
|
| Rate for Payer: Cigna Commercial |
$1,645.06
|
| Rate for Payer: First Health Commercial |
$1,882.90
|
| Rate for Payer: Humana Commercial |
$1,684.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,625.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,462.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,744.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,486.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,585.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,724.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,367.58
|
| Rate for Payer: PHCS Commercial |
$1,902.72
|
| Rate for Payer: United Healthcare All Payer |
$1,744.16
|
|
|
TUMOR IMAGING WHOLE BODY(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
340P0037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$833.66 |
| Rate for Payer: Aetna Commercial |
$833.66
|
| Rate for Payer: Ambetter Exchange |
$506.98
|
| Rate for Payer: Anthem Medicaid |
$492.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$506.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$506.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$608.38
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$742.07
|
| Rate for Payer: Healthspan PPO |
$833.23
|
| Rate for Payer: Humana Medicaid |
$492.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$506.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$506.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$502.47
|
| Rate for Payer: Molina Healthcare Passport |
$492.62
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$659.07
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$497.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$506.98
|
|
|
TUMOR IMAGING WHOLE BODY(T
|
Facility
|
OP
|
$1,832.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
340T0037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$630.02 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem Medicaid |
$630.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,206.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,688.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,628.42
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Humana KY Medicaid |
$630.02
|
| Rate for Payer: Humana Medicare Advantage |
$1,206.24
|
| Rate for Payer: Kentucky WC Medicaid |
$636.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$642.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
TUMOR IMAGING WHOLE BODY(T
|
Facility
|
IP
|
$1,832.00
|
|
|
Service Code
|
HCPCS 78804
|
| Hospital Charge Code |
340T0037
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
TUMOR IMMUNOHISTOCHEM/MANUAL
|
Facility
|
OP
|
$408.00
|
|
|
Service Code
|
HCPCS 88360
|
| Hospital Charge Code |
30001532
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$158.33 |
| Max. Negotiated Rate |
$391.68 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$338.64
|
| Rate for Payer: First Health Commercial |
$387.60
|
| Rate for Payer: Humana Commercial |
$346.80
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$334.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.04
|
| Rate for Payer: Ohio Health Group HMO |
$306.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$281.52
|
| Rate for Payer: PHCS Commercial |
$391.68
|
| Rate for Payer: United Healthcare All Payer |
$359.04
|
|
|
TUMOR IMMUNOHISTOCHEM/MANUAL
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 88360
|
| Hospital Charge Code |
30001532
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$28.02 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Aetna Commercial |
$182.13
|
| Rate for Payer: Ambetter Exchange |
$107.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$107.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$107.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.28
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: Healthspan PPO |
$172.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$107.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.73
|
| Rate for Payer: Multiplan PHCS |
$244.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.05
|
| Rate for Payer: UHCCP Medicaid |
$142.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$107.73
|
|
|
TUMOR IMMUNOHISTOCHEM/MANUAL
|
Facility
|
IP
|
$408.00
|
|
|
Service Code
|
HCPCS 88360
|
| Hospital Charge Code |
30001532
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$391.68 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.62
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna Commercial |
$338.64
|
| Rate for Payer: First Health Commercial |
$387.60
|
| Rate for Payer: Humana Commercial |
$346.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$334.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$301.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$359.04
|
| Rate for Payer: Ohio Health Group HMO |
$306.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$281.52
|
| Rate for Payer: PHCS Commercial |
$391.68
|
| Rate for Payer: United Healthcare All Payer |
$359.04
|
|
|
TUMS (CALCIUM CARBONA TAB/1TAB
|
Facility
|
OP
|
$4.21
|
|
|
Service Code
|
NDC 904641292
|
| Hospital Charge Code |
25001609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$3.49
|
| Rate for Payer: First Health Commercial |
$4.00
|
| Rate for Payer: Humana Commercial |
$3.58
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.70
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Payer |
$3.70
|
|
|
TUMS (CALCIUM CARBONA TAB/1TAB
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 904641292
|
| Hospital Charge Code |
25001609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$3.49
|
| Rate for Payer: First Health Commercial |
$4.00
|
| Rate for Payer: Humana Commercial |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.70
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$4.04
|
| Rate for Payer: United Healthcare All Payer |
$3.70
|
|
