|
CHEMODENERV TRUNK MUSC 1-5
|
Facility
|
OP
|
$1,292.33
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
76102355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$1,240.64 |
| Rate for Payer: Cigna Commercial |
$1,072.63
|
| Rate for Payer: Aetna Commercial |
$995.09
|
| Rate for Payer: Anthem Medicaid |
$444.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$646.16
|
| Rate for Payer: Cash Price |
$646.16
|
| Rate for Payer: First Health Commercial |
$1,227.71
|
| Rate for Payer: Humana Commercial |
$1,098.48
|
| Rate for Payer: Humana KY Medicaid |
$444.43
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$448.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,059.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$953.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.25
|
| Rate for Payer: Ohio Health Group HMO |
$969.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.62
|
| Rate for Payer: PHCS Commercial |
$1,240.64
|
| Rate for Payer: United Healthcare All Payer |
$1,137.25
|
|
|
CHEMODENERV TRUNK MUSC 1-5
|
Professional
|
Both
|
$1,292.33
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
76102355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.61 |
| Max. Negotiated Rate |
$1,292.33 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.61
|
| Rate for Payer: Anthem Medicaid |
$91.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,292.33
|
| Rate for Payer: Cash Price |
$646.16
|
| Rate for Payer: Cash Price |
$646.16
|
| Rate for Payer: Cigna Commercial |
$252.89
|
| Rate for Payer: Healthspan PPO |
$199.50
|
| Rate for Payer: Humana Medicaid |
$91.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$148.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.34
|
| Rate for Payer: Molina Healthcare Passport |
$91.51
|
| Rate for Payer: Multiplan PHCS |
$775.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$904.63
|
| Rate for Payer: UHCCP Medicaid |
$93.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.43
|
|
|
CHEMODENERV TRUNK MUSC 1-5
|
Facility
|
IP
|
$1,292.33
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
76102355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$1,240.64 |
| Rate for Payer: Aetna Commercial |
$995.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.02
|
| Rate for Payer: Cash Price |
$646.16
|
| Rate for Payer: Cigna Commercial |
$1,072.63
|
| Rate for Payer: First Health Commercial |
$1,227.71
|
| Rate for Payer: Humana Commercial |
$1,098.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,059.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$953.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.25
|
| Rate for Payer: Ohio Health Group HMO |
$969.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.62
|
| Rate for Payer: PHCS Commercial |
$1,240.64
|
| Rate for Payer: United Healthcare All Payer |
$1,137.25
|
|
|
CHEMODENERV TRUNK MUSC 1-5(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
761P2355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.61 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.61
|
| Rate for Payer: Anthem Medicaid |
$91.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$252.89
|
| Rate for Payer: Healthspan PPO |
$199.50
|
| Rate for Payer: Humana Medicaid |
$91.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$148.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.34
|
| Rate for Payer: Molina Healthcare Passport |
$91.51
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$93.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.43
|
|
|
CHEMODENERV TRUNK MUSC 1-5(T
|
Facility
|
OP
|
$992.33
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
761T2355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$952.64 |
| Rate for Payer: Aetna Commercial |
$764.09
|
| Rate for Payer: Anthem Medicaid |
$341.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$774.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$496.16
|
| Rate for Payer: Cash Price |
$496.16
|
| Rate for Payer: Cigna Commercial |
$823.63
|
| Rate for Payer: First Health Commercial |
$942.71
|
| Rate for Payer: Humana Commercial |
$843.48
|
| Rate for Payer: Humana KY Medicaid |
$341.26
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$344.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$813.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$732.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$348.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$873.25
|
| Rate for Payer: Ohio Health Group HMO |
$744.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$198.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$307.62
|
| Rate for Payer: PHCS Commercial |
$952.64
|
| Rate for Payer: United Healthcare All Payer |
$873.25
|
|
|
CHEMODENERV TRUNK MUSC 1-5(T
|
Facility
|
IP
|
$992.33
|
|
|
Service Code
|
HCPCS 64646
|
| Hospital Charge Code |
761T2355
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$952.64 |
| Rate for Payer: Aetna Commercial |
$764.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$774.02
|
| Rate for Payer: Cash Price |
$496.16
|
| Rate for Payer: Cigna Commercial |
$823.63
|
| Rate for Payer: First Health Commercial |
$942.71
|
| Rate for Payer: Humana Commercial |
$843.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$813.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$732.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$297.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$873.25
|
| Rate for Payer: Ohio Health Group HMO |
$744.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$198.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$307.62
|
| Rate for Payer: PHCS Commercial |
$952.64
|
| Rate for Payer: United Healthcare All Payer |
$873.25
|
|
|
CHEMODENERV TRUNK MUSC 6/>
|
Facility
|
IP
|
$1,481.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
76102356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.53 |
| Max. Negotiated Rate |
$1,421.76 |
| Rate for Payer: Aetna Commercial |
$1,140.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,155.18
|
| Rate for Payer: Cash Price |
$740.50
|
| Rate for Payer: Cigna Commercial |
$1,229.23
|
| Rate for Payer: First Health Commercial |
$1,406.95
|
| Rate for Payer: Humana Commercial |
$1,258.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,214.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,092.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$444.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,303.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,110.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$459.11
|
| Rate for Payer: PHCS Commercial |
$1,421.76
|
| Rate for Payer: United Healthcare All Payer |
$1,303.28
|
|
|
CHEMODENERV TRUNK MUSC 6/>
|
Facility
|
OP
|
$1,481.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
76102356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.53 |
| Max. Negotiated Rate |
$1,421.76 |
| Rate for Payer: Aetna Commercial |
$1,140.37
|
| Rate for Payer: Anthem Medicaid |
$509.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,155.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$740.50
|
| Rate for Payer: Cash Price |
$740.50
|
| Rate for Payer: Cigna Commercial |
$1,229.23
|
| Rate for Payer: First Health Commercial |
$1,406.95
|
| Rate for Payer: Humana Commercial |
$1,258.85
|
| Rate for Payer: Humana KY Medicaid |
$509.32
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$514.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,214.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,092.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$519.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,303.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,110.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$459.11
|
| Rate for Payer: PHCS Commercial |
$1,421.76
|
| Rate for Payer: United Healthcare All Payer |
$1,303.28
|
|
|
CHEMODENERV TRUNK MUSC 6/>
|
Professional
|
Both
|
$1,481.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
76102356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.74 |
| Max. Negotiated Rate |
$1,481.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.45
|
| Rate for Payer: Anthem Medicaid |
$105.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,481.00
|
| Rate for Payer: Cash Price |
$740.50
|
| Rate for Payer: Cash Price |
$740.50
|
| Rate for Payer: Cigna Commercial |
$292.87
|
| Rate for Payer: Healthspan PPO |
$231.04
|
| Rate for Payer: Humana Medicaid |
$105.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$172.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.85
|
| Rate for Payer: Molina Healthcare Passport |
$105.74
|
| Rate for Payer: Multiplan PHCS |
$888.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,036.70
|
| Rate for Payer: UHCCP Medicaid |
$112.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.80
|
|
|
CHEMODENERV TRUNK MUSC 6/>(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
761P2356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.74 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.45
|
| Rate for Payer: Anthem Medicaid |
$105.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$292.87
|
| Rate for Payer: Healthspan PPO |
$231.04
|
| Rate for Payer: Humana Medicaid |
$105.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$172.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.85
|
| Rate for Payer: Molina Healthcare Passport |
$105.74
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$112.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.80
|
|
|
CHEMODENERV TRUNK MUSC 6/>(T
|
Facility
|
OP
|
$1,131.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
761T2356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.03 |
| Max. Negotiated Rate |
$1,085.76 |
| Rate for Payer: Aetna Commercial |
$870.87
|
| Rate for Payer: Anthem Medicaid |
$388.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$882.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$565.50
|
| Rate for Payer: Cash Price |
$565.50
|
| Rate for Payer: Cigna Commercial |
$938.73
|
| Rate for Payer: First Health Commercial |
$1,074.45
|
| Rate for Payer: Humana Commercial |
$961.35
|
| Rate for Payer: Humana KY Medicaid |
$388.95
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$392.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$927.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$834.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$995.28
|
| Rate for Payer: Ohio Health Group HMO |
$848.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.61
|
| Rate for Payer: PHCS Commercial |
$1,085.76
|
| Rate for Payer: United Healthcare All Payer |
$995.28
|
|
|
CHEMODENERV TRUNK MUSC 6/>(T
|
Facility
|
IP
|
$1,131.00
|
|
|
Service Code
|
HCPCS 64647
|
| Hospital Charge Code |
761T2356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.03 |
| Max. Negotiated Rate |
$1,085.76 |
| Rate for Payer: Aetna Commercial |
$870.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$882.18
|
| Rate for Payer: Cash Price |
$565.50
|
| Rate for Payer: Cigna Commercial |
$938.73
|
| Rate for Payer: First Health Commercial |
$1,074.45
|
| Rate for Payer: Humana Commercial |
$961.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$927.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$834.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$995.28
|
| Rate for Payer: Ohio Health Group HMO |
$848.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.61
|
| Rate for Payer: PHCS Commercial |
$1,085.76
|
| Rate for Payer: United Healthcare All Payer |
$995.28
|
|
|
CHEMO INJ IM SQ HORMONAL
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 96402
|
| Hospital Charge Code |
33100003
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem Medicaid |
$39.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$85.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.24
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Humana KY Medicaid |
$39.55
|
| Rate for Payer: Humana Medicare Advantage |
$60.92
|
| Rate for Payer: Kentucky WC Medicaid |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
CHEMO INJ IM SQ HORMONAL
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 96402
|
| Hospital Charge Code |
33100003
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
CHEMO INJ IM SQ HORMONAL
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 96402
|
| Hospital Charge Code |
33100003
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$35.81 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$55.56
|
| Rate for Payer: Anthem Medicaid |
$35.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.00
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$64.07
|
| Rate for Payer: Healthspan PPO |
$52.06
|
| Rate for Payer: Humana Medicaid |
$35.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$36.53
|
| Rate for Payer: Molina Healthcare Passport |
$35.81
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.50
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.17
|
|
|
CHEMO INJ IM SQ NONHORMONAL
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 96401
|
| Hospital Charge Code |
33100002
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem Medicaid |
$39.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$85.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.24
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Humana KY Medicaid |
$39.55
|
| Rate for Payer: Humana Medicare Advantage |
$60.92
|
| Rate for Payer: Kentucky WC Medicaid |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
CHEMO INJ IM SQ NONHORMONAL
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 96401
|
| Hospital Charge Code |
33100002
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
CHEMO INTRATHECAL INTO CNS
|
Facility
|
IP
|
$962.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
33100010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$125.06 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.22
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
CHEMO INTRATHECAL INTO CNS
|
Facility
|
OP
|
$962.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
33100010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$125.06 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem Medicaid |
$330.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$292.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$410.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$395.36
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Humana KY Medicaid |
$330.83
|
| Rate for Payer: Humana Medicare Advantage |
$292.86
|
| Rate for Payer: Kentucky WC Medicaid |
$334.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$337.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$192.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.22
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
CHEMO INTRATHECAL INTO CNS
|
Professional
|
Both
|
$962.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
33100010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$50.84 |
| Max. Negotiated Rate |
$962.00 |
| Rate for Payer: Aetna Commercial |
$138.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.84
|
| Rate for Payer: Anthem Medicaid |
$88.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$962.00
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$155.60
|
| Rate for Payer: Healthspan PPO |
$296.90
|
| Rate for Payer: Humana Medicaid |
$88.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.37
|
| Rate for Payer: Molina Healthcare Passport |
$88.60
|
| Rate for Payer: Multiplan PHCS |
$577.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$673.40
|
| Rate for Payer: UHCCP Medicaid |
$53.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.49
|
|
|
CHEMO INTRATHECAL INTO CNS(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
331P0010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$50.84 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$138.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.84
|
| Rate for Payer: Anthem Medicaid |
$88.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$155.60
|
| Rate for Payer: Healthspan PPO |
$296.90
|
| Rate for Payer: Humana Medicaid |
$88.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.37
|
| Rate for Payer: Molina Healthcare Passport |
$88.60
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$53.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.49
|
|
|
CHEMO INTRATHECAL INTO CNS(T
|
Facility
|
IP
|
$512.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
331T0010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$66.56 |
| Max. Negotiated Rate |
$491.52 |
| Rate for Payer: Aetna Commercial |
$394.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$399.36
|
| Rate for Payer: Cash Price |
$256.00
|
| Rate for Payer: Cigna Commercial |
$424.96
|
| Rate for Payer: First Health Commercial |
$486.40
|
| Rate for Payer: Humana Commercial |
$435.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$419.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$377.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$450.56
|
| Rate for Payer: Ohio Health Group HMO |
$384.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.72
|
| Rate for Payer: PHCS Commercial |
$491.52
|
| Rate for Payer: United Healthcare All Payer |
$450.56
|
|
|
CHEMO INTRATHECAL INTO CNS(T
|
Facility
|
OP
|
$512.00
|
|
|
Service Code
|
HCPCS 96450
|
| Hospital Charge Code |
331T0010
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$66.56 |
| Max. Negotiated Rate |
$491.52 |
| Rate for Payer: Aetna Commercial |
$394.24
|
| Rate for Payer: Anthem Medicaid |
$176.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$292.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$399.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$410.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$395.36
|
| Rate for Payer: Cash Price |
$256.00
|
| Rate for Payer: Cash Price |
$256.00
|
| Rate for Payer: Cigna Commercial |
$424.96
|
| Rate for Payer: First Health Commercial |
$486.40
|
| Rate for Payer: Humana Commercial |
$435.20
|
| Rate for Payer: Humana KY Medicaid |
$176.08
|
| Rate for Payer: Humana Medicare Advantage |
$292.86
|
| Rate for Payer: Kentucky WC Medicaid |
$177.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$419.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$377.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$450.56
|
| Rate for Payer: Ohio Health Group HMO |
$384.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.72
|
| Rate for Payer: PHCS Commercial |
$491.52
|
| Rate for Payer: United Healthcare All Payer |
$450.56
|
|
|
CHEMO IV INFUSION EA ADDL HR
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
HCPCS 96415
|
| Hospital Charge Code |
33100007
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$97.92 |
| Rate for Payer: Aetna Commercial |
$78.54
|
| Rate for Payer: Anthem Medicaid |
$35.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$85.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.24
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$84.66
|
| Rate for Payer: First Health Commercial |
$96.90
|
| Rate for Payer: Humana Commercial |
$86.70
|
| Rate for Payer: Humana KY Medicaid |
$35.08
|
| Rate for Payer: Humana Medicare Advantage |
$60.92
|
| Rate for Payer: Kentucky WC Medicaid |
$35.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.76
|
| Rate for Payer: Ohio Health Group HMO |
$76.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.62
|
| Rate for Payer: PHCS Commercial |
$97.92
|
| Rate for Payer: United Healthcare All Payer |
$89.76
|
|
|
CHEMO IV INFUSION EA ADDL HR
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
HCPCS 96415
|
| Hospital Charge Code |
33100007
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$13.26 |
| Max. Negotiated Rate |
$97.92 |
| Rate for Payer: Aetna Commercial |
$78.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.56
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$84.66
|
| Rate for Payer: First Health Commercial |
$96.90
|
| Rate for Payer: Humana Commercial |
$86.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.76
|
| Rate for Payer: Ohio Health Group HMO |
$76.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.62
|
| Rate for Payer: PHCS Commercial |
$97.92
|
| Rate for Payer: United Healthcare All Payer |
$89.76
|
|
