|
VISUAL ACUITY SCREEN(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510P0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$45.90 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$45.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$3.45
|
| Rate for Payer: Healthspan PPO |
$3.45
|
| Rate for Payer: Humana Medicaid |
$45.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.90
|
| Rate for Payer: Molina Healthcare Passport |
$45.00
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.45
|
|
|
VISUAL ACUITY SCREEN(T
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510T0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.61
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
VISUAL ACUITY SCREEN(T
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS 99173
|
| Hospital Charge Code |
510T0059
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem Medicaid |
$10.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Humana KY Medicaid |
$10.66
|
| Rate for Payer: Kentucky WC Medicaid |
$10.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.61
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
VISUAL AUDIOMETRY
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS 92579
|
| Hospital Charge Code |
47000015
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Aetna Commercial |
$254.10
|
| Rate for Payer: Anthem Medicaid |
$113.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$273.90
|
| Rate for Payer: First Health Commercial |
$313.50
|
| Rate for Payer: Humana Commercial |
$280.50
|
| Rate for Payer: Humana KY Medicaid |
$113.49
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$114.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.40
|
| Rate for Payer: Ohio Health Group HMO |
$247.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.30
|
| Rate for Payer: PHCS Commercial |
$316.80
|
| Rate for Payer: United Healthcare All Payer |
$290.40
|
|
|
VISUAL AUDIOMETRY
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS 92579
|
| Hospital Charge Code |
47000015
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Aetna Commercial |
$254.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.40
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$273.90
|
| Rate for Payer: First Health Commercial |
$313.50
|
| Rate for Payer: Humana Commercial |
$280.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.40
|
| Rate for Payer: Ohio Health Group HMO |
$247.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.30
|
| Rate for Payer: PHCS Commercial |
$316.80
|
| Rate for Payer: United Healthcare All Payer |
$290.40
|
|
|
VISUAL FLD EXAM
|
Facility
|
IP
|
$251.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
76102448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.70 |
| Max. Negotiated Rate |
$241.44 |
| Rate for Payer: Aetna Commercial |
$193.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.17
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cigna Commercial |
$208.74
|
| Rate for Payer: First Health Commercial |
$238.92
|
| Rate for Payer: Humana Commercial |
$213.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.32
|
| Rate for Payer: Ohio Health Group HMO |
$188.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.96
|
| Rate for Payer: PHCS Commercial |
$241.44
|
| Rate for Payer: United Healthcare All Payer |
$221.32
|
|
|
VISUAL FLD EXAM
|
Facility
|
OP
|
$251.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
76102448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.70 |
| Max. Negotiated Rate |
$241.44 |
| Rate for Payer: Aetna Commercial |
$193.66
|
| Rate for Payer: Anthem Medicaid |
$86.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cigna Commercial |
$208.74
|
| Rate for Payer: First Health Commercial |
$238.92
|
| Rate for Payer: Humana Commercial |
$213.78
|
| Rate for Payer: Humana KY Medicaid |
$86.49
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$87.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.32
|
| Rate for Payer: Ohio Health Group HMO |
$188.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.96
|
| Rate for Payer: PHCS Commercial |
$241.44
|
| Rate for Payer: United Healthcare All Payer |
$221.32
|
|
|
VISUAL FLD EXAM
|
Professional
|
Both
|
$251.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
76102448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$251.50 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Anthem Medicaid |
$36.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$251.50
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cash Price |
$125.75
|
| Rate for Payer: Cigna Commercial |
$69.26
|
| Rate for Payer: Healthspan PPO |
$59.78
|
| Rate for Payer: Humana Medicaid |
$36.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.18
|
| Rate for Payer: Molina Healthcare Passport |
$36.45
|
| Rate for Payer: Multiplan PHCS |
$150.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$176.05
|
| Rate for Payer: UHCCP Medicaid |
$88.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.81
|
|
|
VISUAL FLD EXAM(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
761P2448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.79 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Anthem Medicaid |
$36.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$69.26
|
| Rate for Payer: Healthspan PPO |
$59.78
|
| Rate for Payer: Humana Medicaid |
$36.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.18
|
| Rate for Payer: Molina Healthcare Passport |
$36.45
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.81
|
|
|
VISUAL FLD EXAM(T
|
Facility
|
IP
|
$131.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
761T2448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$126.24 |
| Rate for Payer: Aetna Commercial |
$101.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.57
|
| Rate for Payer: Cash Price |
$65.75
|
| Rate for Payer: Cigna Commercial |
$109.14
|
| Rate for Payer: First Health Commercial |
$124.92
|
| Rate for Payer: Humana Commercial |
$111.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.72
|
| Rate for Payer: Ohio Health Group HMO |
$98.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.76
|
| Rate for Payer: PHCS Commercial |
$126.24
|
| Rate for Payer: United Healthcare All Payer |
$115.72
|
|
|
VISUAL FLD EXAM(T
|
Facility
|
OP
|
$131.50
|
|
|
Service Code
|
HCPCS 92081
|
| Hospital Charge Code |
761T2448
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$126.24 |
| Rate for Payer: Aetna Commercial |
$101.26
|
| Rate for Payer: Anthem Medicaid |
$45.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$65.75
|
| Rate for Payer: Cash Price |
$65.75
|
| Rate for Payer: Cigna Commercial |
$109.14
|
| Rate for Payer: First Health Commercial |
$124.92
|
| Rate for Payer: Humana Commercial |
$111.78
|
| Rate for Payer: Humana KY Medicaid |
$45.22
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$45.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.72
|
| Rate for Payer: Ohio Health Group HMO |
$98.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.76
|
| Rate for Payer: PHCS Commercial |
$126.24
|
| Rate for Payer: United Healthcare All Payer |
$115.72
|
|
|
VITAL
|
Facility
|
IP
|
$69.48
|
|
|
Service Code
|
NDC 70074056543
|
| Hospital Charge Code |
27000103
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$66.70 |
| Rate for Payer: Aetna Commercial |
$53.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.19
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Cigna Commercial |
$57.67
|
| Rate for Payer: First Health Commercial |
$66.01
|
| Rate for Payer: Humana Commercial |
$59.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.14
|
| Rate for Payer: Ohio Health Group HMO |
$52.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.54
|
| Rate for Payer: PHCS Commercial |
$66.70
|
| Rate for Payer: United Healthcare All Payer |
$61.14
|
|
|
VITAL
|
Facility
|
OP
|
$69.48
|
|
|
Service Code
|
NDC 70074056543
|
| Hospital Charge Code |
27000103
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$66.70 |
| Rate for Payer: Aetna Commercial |
$53.50
|
| Rate for Payer: Anthem Medicaid |
$23.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.19
|
| Rate for Payer: Cash Price |
$34.74
|
| Rate for Payer: Cigna Commercial |
$57.67
|
| Rate for Payer: First Health Commercial |
$66.01
|
| Rate for Payer: Humana Commercial |
$59.06
|
| Rate for Payer: Humana KY Medicaid |
$23.89
|
| Rate for Payer: Kentucky WC Medicaid |
$24.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.14
|
| Rate for Payer: Ohio Health Group HMO |
$52.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.54
|
| Rate for Payer: PHCS Commercial |
$66.70
|
| Rate for Payer: United Healthcare All Payer |
$61.14
|
|
|
VITAL 1.5Cal 1,000 mL Bottle
|
Facility
|
OP
|
$98.78
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
25004381
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$94.83 |
| Rate for Payer: Aetna Commercial |
$76.06
|
| Rate for Payer: Anthem Medicaid |
$33.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.05
|
| Rate for Payer: Cash Price |
$49.39
|
| Rate for Payer: Cigna Commercial |
$81.99
|
| Rate for Payer: First Health Commercial |
$93.84
|
| Rate for Payer: Humana Commercial |
$83.96
|
| Rate for Payer: Humana KY Medicaid |
$33.97
|
| Rate for Payer: Kentucky WC Medicaid |
$34.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.93
|
| Rate for Payer: Ohio Health Group HMO |
$74.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.62
|
| Rate for Payer: PHCS Commercial |
$94.83
|
| Rate for Payer: United Healthcare All Payer |
$86.93
|
|
|
VITAL 1.5Cal 1,000 mL Bottle
|
Facility
|
IP
|
$98.78
|
|
|
Service Code
|
HCPCS B4153
|
| Hospital Charge Code |
25004381
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$94.83 |
| Rate for Payer: Aetna Commercial |
$76.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.05
|
| Rate for Payer: Cash Price |
$49.39
|
| Rate for Payer: Cigna Commercial |
$81.99
|
| Rate for Payer: First Health Commercial |
$93.84
|
| Rate for Payer: Humana Commercial |
$83.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.93
|
| Rate for Payer: Ohio Health Group HMO |
$74.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.62
|
| Rate for Payer: PHCS Commercial |
$94.83
|
| Rate for Payer: United Healthcare All Payer |
$86.93
|
|
|
VITAL-AF 1.2CAL 1.5L TUBEFEED
|
Facility
|
IP
|
$91.75
|
|
|
Service Code
|
NDC 70074067642
|
| Hospital Charge Code |
25003728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$88.08 |
| Rate for Payer: Aetna Commercial |
$70.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.56
|
| Rate for Payer: Cash Price |
$45.88
|
| Rate for Payer: Cigna Commercial |
$76.15
|
| Rate for Payer: First Health Commercial |
$87.16
|
| Rate for Payer: Humana Commercial |
$77.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.74
|
| Rate for Payer: Ohio Health Group HMO |
$68.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.44
|
| Rate for Payer: PHCS Commercial |
$88.08
|
| Rate for Payer: United Healthcare All Payer |
$80.74
|
|
|
VITAL-AF 1.2CAL 1.5L TUBEFEED
|
Facility
|
OP
|
$91.75
|
|
|
Service Code
|
NDC 70074067642
|
| Hospital Charge Code |
25003728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$88.08 |
| Rate for Payer: Aetna Commercial |
$70.65
|
| Rate for Payer: Anthem Medicaid |
$31.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.56
|
| Rate for Payer: Cash Price |
$45.88
|
| Rate for Payer: Cigna Commercial |
$76.15
|
| Rate for Payer: First Health Commercial |
$87.16
|
| Rate for Payer: Humana Commercial |
$77.99
|
| Rate for Payer: Humana KY Medicaid |
$31.55
|
| Rate for Payer: Kentucky WC Medicaid |
$31.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.74
|
| Rate for Payer: Ohio Health Group HMO |
$68.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.44
|
| Rate for Payer: PHCS Commercial |
$88.08
|
| Rate for Payer: United Healthcare All Payer |
$80.74
|
|
|
VITALAF 1.2CAL NUTSUP TF1000ML
|
Facility
|
OP
|
$94.67
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
25003579
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$90.88 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Anthem Medicaid |
$32.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.84
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna Commercial |
$78.58
|
| Rate for Payer: First Health Commercial |
$89.94
|
| Rate for Payer: Humana Commercial |
$80.47
|
| Rate for Payer: Humana KY Medicaid |
$32.56
|
| Rate for Payer: Kentucky WC Medicaid |
$32.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.31
|
| Rate for Payer: Ohio Health Group HMO |
$71.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.35
|
| Rate for Payer: PHCS Commercial |
$90.88
|
| Rate for Payer: United Healthcare All Payer |
$83.31
|
|
|
VITALAF 1.2CAL NUTSUP TF1000ML
|
Facility
|
IP
|
$94.67
|
|
|
Service Code
|
NDC 70074062715
|
| Hospital Charge Code |
25003579
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.31 |
| Max. Negotiated Rate |
$90.88 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.84
|
| Rate for Payer: Cash Price |
$47.34
|
| Rate for Payer: Cigna Commercial |
$78.58
|
| Rate for Payer: First Health Commercial |
$89.94
|
| Rate for Payer: Humana Commercial |
$80.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.31
|
| Rate for Payer: Ohio Health Group HMO |
$71.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.35
|
| Rate for Payer: PHCS Commercial |
$90.88
|
| Rate for Payer: United Healthcare All Payer |
$83.31
|
|
|
VITAL CAPACITY EACH PROCEDURE
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
46000004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem Medicaid |
$168.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Humana KY Medicaid |
$168.51
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$170.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$171.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.90
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
VITAL CAPACITY EACH PROCEDURE
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
46000004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$490.00 |
| Rate for Payer: Aetna Commercial |
$33.83
|
| Rate for Payer: Anthem Medicaid |
$9.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$490.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$31.16
|
| Rate for Payer: Healthspan PPO |
$26.62
|
| Rate for Payer: Humana Medicaid |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$9.26
|
| Rate for Payer: Molina Healthcare Passport |
$9.08
|
| Rate for Payer: Multiplan PHCS |
$294.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$343.00
|
| Rate for Payer: UHCCP Medicaid |
$171.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$9.17
|
|
|
VITAL CAPACITY EACH PROCEDURE
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
46000004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.20
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.90
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
VITAL CAPACITY EACH PROCEDUR(P
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
460P0004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$4.71 |
| Max. Negotiated Rate |
$33.83 |
| Rate for Payer: Aetna Commercial |
$33.83
|
| Rate for Payer: Anthem Medicaid |
$9.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.00
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$31.16
|
| Rate for Payer: Healthspan PPO |
$26.62
|
| Rate for Payer: Humana Medicaid |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$9.26
|
| Rate for Payer: Molina Healthcare Passport |
$9.08
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$9.17
|
|
|
VITAL CAPACITY EACH PROCEDUR(T
|
Facility
|
IP
|
$465.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
460T0004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$60.45 |
| Max. Negotiated Rate |
$446.40 |
| Rate for Payer: Aetna Commercial |
$358.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$362.70
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cigna Commercial |
$385.95
|
| Rate for Payer: First Health Commercial |
$441.75
|
| Rate for Payer: Humana Commercial |
$395.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$381.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$343.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$139.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$409.20
|
| Rate for Payer: Ohio Health Group HMO |
$348.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.15
|
| Rate for Payer: PHCS Commercial |
$446.40
|
| Rate for Payer: United Healthcare All Payer |
$409.20
|
|
|
VITAL CAPACITY EACH PROCEDUR(T
|
Facility
|
OP
|
$465.00
|
|
|
Service Code
|
HCPCS 94150
|
| Hospital Charge Code |
460T0004
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$60.45 |
| Max. Negotiated Rate |
$446.40 |
| Rate for Payer: Aetna Commercial |
$358.05
|
| Rate for Payer: Anthem Medicaid |
$159.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$362.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cigna Commercial |
$385.95
|
| Rate for Payer: First Health Commercial |
$441.75
|
| Rate for Payer: Humana Commercial |
$395.25
|
| Rate for Payer: Humana KY Medicaid |
$159.91
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$161.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$381.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$343.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$163.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$409.20
|
| Rate for Payer: Ohio Health Group HMO |
$348.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.15
|
| Rate for Payer: PHCS Commercial |
$446.40
|
| Rate for Payer: United Healthcare All Payer |
$409.20
|
|
