|
CT ABD & PELV 1/> REGNS(T
|
Facility
|
IP
|
$5,231.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
350T0064
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$680.03 |
| Max. Negotiated Rate |
$5,021.76 |
| Rate for Payer: Aetna Commercial |
$4,027.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,080.18
|
| Rate for Payer: Cash Price |
$2,615.50
|
| Rate for Payer: Cigna Commercial |
$4,341.73
|
| Rate for Payer: First Health Commercial |
$4,969.45
|
| Rate for Payer: Humana Commercial |
$4,446.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,289.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,860.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,569.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,603.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,923.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,046.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$680.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,621.61
|
| Rate for Payer: PHCS Commercial |
$5,021.76
|
| Rate for Payer: United Healthcare All Payer |
$4,603.28
|
|
|
CT ABD & PELVIS W/O CONTRAS(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
350P0062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$358.21 |
| Rate for Payer: Aetna Commercial |
$338.25
|
| Rate for Payer: Anthem Medicaid |
$189.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$358.21
|
| Rate for Payer: Healthspan PPO |
$174.93
|
| Rate for Payer: Humana Medicaid |
$189.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.78
|
| Rate for Payer: Molina Healthcare Passport |
$189.00
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.89
|
|
|
CT ABD & PELVIS W/O CONTRAS(T
|
Facility
|
IP
|
$4,486.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
350T0062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$583.18 |
| Max. Negotiated Rate |
$4,306.56 |
| Rate for Payer: Aetna Commercial |
$3,454.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,499.08
|
| Rate for Payer: Cash Price |
$2,243.00
|
| Rate for Payer: Cigna Commercial |
$3,723.38
|
| Rate for Payer: First Health Commercial |
$4,261.70
|
| Rate for Payer: Humana Commercial |
$3,813.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,678.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,310.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,345.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,947.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,364.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$897.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,390.66
|
| Rate for Payer: PHCS Commercial |
$4,306.56
|
| Rate for Payer: United Healthcare All Payer |
$3,947.68
|
|
|
CT ABD & PELVIS W/O CONTRAS(T
|
Facility
|
OP
|
$4,486.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
350T0062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$211.90 |
| Max. Negotiated Rate |
$4,306.56 |
| Rate for Payer: Aetna Commercial |
$3,454.22
|
| Rate for Payer: Anthem Medicaid |
$1,542.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,499.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$2,243.00
|
| Rate for Payer: Cash Price |
$2,243.00
|
| Rate for Payer: Cigna Commercial |
$3,723.38
|
| Rate for Payer: First Health Commercial |
$4,261.70
|
| Rate for Payer: Humana Commercial |
$3,813.10
|
| Rate for Payer: Humana KY Medicaid |
$1,542.74
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,558.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,678.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,310.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,573.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,947.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,364.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$897.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,390.66
|
| Rate for Payer: PHCS Commercial |
$4,306.56
|
| Rate for Payer: United Healthcare All Payer |
$3,947.68
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Facility
|
OP
|
$4,661.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$211.90 |
| Max. Negotiated Rate |
$4,474.56 |
| Rate for Payer: Aetna Commercial |
$3,588.97
|
| Rate for Payer: Anthem Medicaid |
$1,602.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,635.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$2,330.50
|
| Rate for Payer: Cash Price |
$2,330.50
|
| Rate for Payer: Cigna Commercial |
$3,868.63
|
| Rate for Payer: First Health Commercial |
$4,427.95
|
| Rate for Payer: Humana Commercial |
$3,961.85
|
| Rate for Payer: Humana KY Medicaid |
$1,602.92
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,619.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,822.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,439.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,635.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,101.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,495.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$932.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$605.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,444.91
|
| Rate for Payer: PHCS Commercial |
$4,474.56
|
| Rate for Payer: United Healthcare All Payer |
$4,101.68
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Facility
|
IP
|
$4,661.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$605.93 |
| Max. Negotiated Rate |
$4,474.56 |
| Rate for Payer: Aetna Commercial |
$3,588.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,635.58
|
| Rate for Payer: Cash Price |
$2,330.50
|
| Rate for Payer: Cigna Commercial |
$3,868.63
|
| Rate for Payer: First Health Commercial |
$4,427.95
|
| Rate for Payer: Humana Commercial |
$3,961.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,822.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,439.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,398.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,101.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,495.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$932.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$605.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,444.91
|
| Rate for Payer: PHCS Commercial |
$4,474.56
|
| Rate for Payer: United Healthcare All Payer |
$4,101.68
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Professional
|
Both
|
$4,661.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$107.86 |
| Max. Negotiated Rate |
$4,661.00 |
| Rate for Payer: Aetna Commercial |
$338.25
|
| Rate for Payer: Anthem Medicaid |
$189.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,661.00
|
| Rate for Payer: Cash Price |
$2,330.50
|
| Rate for Payer: Cash Price |
$2,330.50
|
| Rate for Payer: Cigna Commercial |
$358.21
|
| Rate for Payer: Healthspan PPO |
$174.93
|
| Rate for Payer: Humana Medicaid |
$189.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.78
|
| Rate for Payer: Molina Healthcare Passport |
$189.00
|
| Rate for Payer: Multiplan PHCS |
$2,796.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,262.70
|
| Rate for Payer: UHCCP Medicaid |
$1,631.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.89
|
|
|
CT ABD & PELV W/CONTRAST
|
Professional
|
Both
|
$5,020.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$113.01 |
| Max. Negotiated Rate |
$5,020.00 |
| Rate for Payer: Aetna Commercial |
$528.69
|
| Rate for Payer: Anthem Medicaid |
$297.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,020.00
|
| Rate for Payer: Cash Price |
$2,510.00
|
| Rate for Payer: Cash Price |
$2,510.00
|
| Rate for Payer: Cigna Commercial |
$559.23
|
| Rate for Payer: Healthspan PPO |
$273.49
|
| Rate for Payer: Humana Medicaid |
$297.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$302.94
|
| Rate for Payer: Molina Healthcare Passport |
$297.00
|
| Rate for Payer: Multiplan PHCS |
$3,012.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,514.00
|
| Rate for Payer: UHCCP Medicaid |
$1,757.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.97
|
|
|
CT ABD & PELV W/CONTRAST
|
Facility
|
IP
|
$5,020.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$652.60 |
| Max. Negotiated Rate |
$4,819.20 |
| Rate for Payer: Aetna Commercial |
$3,865.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,915.60
|
| Rate for Payer: Cash Price |
$2,510.00
|
| Rate for Payer: Cigna Commercial |
$4,166.60
|
| Rate for Payer: First Health Commercial |
$4,769.00
|
| Rate for Payer: Humana Commercial |
$4,267.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,116.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,704.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,506.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,417.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,765.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,556.20
|
| Rate for Payer: PHCS Commercial |
$4,819.20
|
| Rate for Payer: United Healthcare All Payer |
$4,417.60
|
|
|
CT ABD & PELV W/CONTRAST
|
Facility
|
OP
|
$5,020.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$332.56 |
| Max. Negotiated Rate |
$4,819.20 |
| Rate for Payer: Aetna Commercial |
$3,865.40
|
| Rate for Payer: Anthem Medicaid |
$1,726.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$332.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,915.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$465.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$448.96
|
| Rate for Payer: Cash Price |
$2,510.00
|
| Rate for Payer: Cash Price |
$2,510.00
|
| Rate for Payer: Cigna Commercial |
$4,166.60
|
| Rate for Payer: First Health Commercial |
$4,769.00
|
| Rate for Payer: Humana Commercial |
$4,267.00
|
| Rate for Payer: Humana KY Medicaid |
$1,726.38
|
| Rate for Payer: Humana Medicare Advantage |
$332.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,743.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,116.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,704.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,761.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,417.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,765.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,556.20
|
| Rate for Payer: PHCS Commercial |
$4,819.20
|
| Rate for Payer: United Healthcare All Payer |
$4,417.60
|
|
|
CT ABD & PELV W/CONTRAST(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
350P0063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$559.23 |
| Rate for Payer: Aetna Commercial |
$528.69
|
| Rate for Payer: Anthem Medicaid |
$297.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$559.23
|
| Rate for Payer: Healthspan PPO |
$273.49
|
| Rate for Payer: Humana Medicaid |
$297.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$302.94
|
| Rate for Payer: Molina Healthcare Passport |
$297.00
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.97
|
|
|
CT ABD & PELV W/CONTRAST(T
|
Facility
|
IP
|
$4,845.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
350T0063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$629.85 |
| Max. Negotiated Rate |
$4,651.20 |
| Rate for Payer: Aetna Commercial |
$3,730.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,779.10
|
| Rate for Payer: Cash Price |
$2,422.50
|
| Rate for Payer: Cigna Commercial |
$4,021.35
|
| Rate for Payer: First Health Commercial |
$4,602.75
|
| Rate for Payer: Humana Commercial |
$4,118.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,972.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,575.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,453.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,263.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,633.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,501.95
|
| Rate for Payer: PHCS Commercial |
$4,651.20
|
| Rate for Payer: United Healthcare All Payer |
$4,263.60
|
|
|
CT ABD & PELV W/CONTRAST(T
|
Facility
|
OP
|
$4,845.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
350T0063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$332.56 |
| Max. Negotiated Rate |
$4,651.20 |
| Rate for Payer: Aetna Commercial |
$3,730.65
|
| Rate for Payer: Anthem Medicaid |
$1,666.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$332.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,779.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$465.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$448.96
|
| Rate for Payer: Cash Price |
$2,422.50
|
| Rate for Payer: Cash Price |
$2,422.50
|
| Rate for Payer: Cigna Commercial |
$4,021.35
|
| Rate for Payer: First Health Commercial |
$4,602.75
|
| Rate for Payer: Humana Commercial |
$4,118.25
|
| Rate for Payer: Humana KY Medicaid |
$1,666.20
|
| Rate for Payer: Humana Medicare Advantage |
$332.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,683.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,972.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,575.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,699.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,263.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,633.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,501.95
|
| Rate for Payer: PHCS Commercial |
$4,651.20
|
| Rate for Payer: United Healthcare All Payer |
$4,263.60
|
|
|
CTA BRAIN PERFUSION
|
Facility
|
IP
|
$1,783.00
|
|
|
Service Code
|
HCPCS 0042T
|
| Hospital Charge Code |
35000033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$231.79 |
| Max. Negotiated Rate |
$1,711.68 |
| Rate for Payer: Aetna Commercial |
$1,372.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,390.74
|
| Rate for Payer: Cash Price |
$891.50
|
| Rate for Payer: Cigna Commercial |
$1,479.89
|
| Rate for Payer: First Health Commercial |
$1,693.85
|
| Rate for Payer: Humana Commercial |
$1,515.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,315.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$534.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,337.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.73
|
| Rate for Payer: PHCS Commercial |
$1,711.68
|
| Rate for Payer: United Healthcare All Payer |
$1,569.04
|
|
|
CTA BRAIN PERFUSION
|
Facility
|
OP
|
$1,783.00
|
|
|
Service Code
|
HCPCS 0042T
|
| Hospital Charge Code |
35000033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$231.79 |
| Max. Negotiated Rate |
$1,711.68 |
| Rate for Payer: Aetna Commercial |
$1,372.91
|
| Rate for Payer: Anthem Medicaid |
$613.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,390.74
|
| Rate for Payer: Cash Price |
$891.50
|
| Rate for Payer: Cigna Commercial |
$1,479.89
|
| Rate for Payer: First Health Commercial |
$1,693.85
|
| Rate for Payer: Humana Commercial |
$1,515.55
|
| Rate for Payer: Humana KY Medicaid |
$613.17
|
| Rate for Payer: Kentucky WC Medicaid |
$619.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,315.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$534.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,337.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.73
|
| Rate for Payer: PHCS Commercial |
$1,711.68
|
| Rate for Payer: United Healthcare All Payer |
$1,569.04
|
|
|
CTA CIRCLE OF WILLIS
|
Facility
|
IP
|
$3,353.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$435.89 |
| Max. Negotiated Rate |
$3,218.88 |
| Rate for Payer: Aetna Commercial |
$2,581.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,615.34
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cigna Commercial |
$2,782.99
|
| Rate for Payer: First Health Commercial |
$3,185.35
|
| Rate for Payer: Humana Commercial |
$2,850.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,749.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,474.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,005.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,950.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,514.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$670.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,039.43
|
| Rate for Payer: PHCS Commercial |
$3,218.88
|
| Rate for Payer: United Healthcare All Payer |
$2,950.64
|
|
|
CTA CIRCLE OF WILLIS
|
Facility
|
OP
|
$3,353.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$3,218.88 |
| Rate for Payer: Aetna Commercial |
$2,581.81
|
| Rate for Payer: Anthem Medicaid |
$1,153.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,615.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cigna Commercial |
$2,782.99
|
| Rate for Payer: First Health Commercial |
$3,185.35
|
| Rate for Payer: Humana Commercial |
$2,850.05
|
| Rate for Payer: Humana KY Medicaid |
$1,153.10
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,164.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,749.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,474.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,176.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,950.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,514.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$670.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,039.43
|
| Rate for Payer: PHCS Commercial |
$3,218.88
|
| Rate for Payer: United Healthcare All Payer |
$2,950.64
|
|
|
CTA CIRCLE OF WILLIS
|
Professional
|
Both
|
$3,353.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$111.63 |
| Max. Negotiated Rate |
$3,353.00 |
| Rate for Payer: Healthspan PPO |
$461.03
|
| Rate for Payer: Aetna Commercial |
$670.94
|
| Rate for Payer: Anthem Medicaid |
$262.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,353.00
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cigna Commercial |
$815.51
|
| Rate for Payer: Humana Medicaid |
$262.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$268.13
|
| Rate for Payer: Molina Healthcare Passport |
$262.87
|
| Rate for Payer: Multiplan PHCS |
$2,011.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,347.10
|
| Rate for Payer: UHCCP Medicaid |
$1,173.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$265.50
|
|
|
CTA CIRCLE OF WILLIS(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
350P0031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$815.51 |
| Rate for Payer: Aetna Commercial |
$670.94
|
| Rate for Payer: Anthem Medicaid |
$262.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$815.51
|
| Rate for Payer: Healthspan PPO |
$461.03
|
| Rate for Payer: Humana Medicaid |
$262.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$268.13
|
| Rate for Payer: Molina Healthcare Passport |
$262.87
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$265.50
|
|
|
CTA CIRCLE OF WILLIS(T
|
Facility
|
IP
|
$3,128.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
350T0031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$406.64 |
| Max. Negotiated Rate |
$3,002.88 |
| Rate for Payer: Aetna Commercial |
$2,408.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,439.84
|
| Rate for Payer: Cash Price |
$1,564.00
|
| Rate for Payer: Cigna Commercial |
$2,596.24
|
| Rate for Payer: First Health Commercial |
$2,971.60
|
| Rate for Payer: Humana Commercial |
$2,658.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,564.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,308.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$938.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,752.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,346.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$625.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$969.68
|
| Rate for Payer: PHCS Commercial |
$3,002.88
|
| Rate for Payer: United Healthcare All Payer |
$2,752.64
|
|
|
CTA CIRCLE OF WILLIS(T
|
Facility
|
OP
|
$3,128.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
350T0031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$3,002.88 |
| Rate for Payer: Aetna Commercial |
$2,408.56
|
| Rate for Payer: Anthem Medicaid |
$1,075.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,439.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,564.00
|
| Rate for Payer: Cash Price |
$1,564.00
|
| Rate for Payer: Cigna Commercial |
$2,596.24
|
| Rate for Payer: First Health Commercial |
$2,971.60
|
| Rate for Payer: Humana Commercial |
$2,658.80
|
| Rate for Payer: Humana KY Medicaid |
$1,075.72
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,086.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,564.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,308.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,097.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,752.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,346.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$625.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$969.68
|
| Rate for Payer: PHCS Commercial |
$3,002.88
|
| Rate for Payer: United Healthcare All Payer |
$2,752.64
|
|
|
[C]TALWIN NX (PENT/ 50MG/1TAB
|
Facility
|
OP
|
$62.06
|
|
|
Service Code
|
NDC 591039501
|
| Hospital Charge Code |
25000082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$59.58 |
| Rate for Payer: Aetna Commercial |
$47.79
|
| Rate for Payer: Anthem Medicaid |
$21.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.41
|
| Rate for Payer: Cash Price |
$31.03
|
| Rate for Payer: Cigna Commercial |
$51.51
|
| Rate for Payer: First Health Commercial |
$58.96
|
| Rate for Payer: Humana Commercial |
$52.75
|
| Rate for Payer: Humana KY Medicaid |
$21.34
|
| Rate for Payer: Kentucky WC Medicaid |
$21.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.61
|
| Rate for Payer: Ohio Health Group HMO |
$46.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.24
|
| Rate for Payer: PHCS Commercial |
$59.58
|
| Rate for Payer: United Healthcare All Payer |
$54.61
|
|
|
[C]TALWIN NX (PENT/ 50MG/1TAB
|
Facility
|
IP
|
$62.06
|
|
|
Service Code
|
NDC 591039501
|
| Hospital Charge Code |
25000082
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$59.58 |
| Rate for Payer: Aetna Commercial |
$47.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.41
|
| Rate for Payer: Cash Price |
$31.03
|
| Rate for Payer: Cigna Commercial |
$51.51
|
| Rate for Payer: First Health Commercial |
$58.96
|
| Rate for Payer: Humana Commercial |
$52.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.61
|
| Rate for Payer: Ohio Health Group HMO |
$46.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.24
|
| Rate for Payer: PHCS Commercial |
$59.58
|
| Rate for Payer: United Healthcare All Payer |
$54.61
|
|
|
CT ANGIO ABDOMINAL ARTERIES
|
Facility
|
OP
|
$3,403.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
35000013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$3,266.88 |
| Rate for Payer: Aetna Commercial |
$2,620.31
|
| Rate for Payer: Anthem Medicaid |
$1,170.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,654.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,701.50
|
| Rate for Payer: Cash Price |
$1,701.50
|
| Rate for Payer: Cigna Commercial |
$2,824.49
|
| Rate for Payer: First Health Commercial |
$3,232.85
|
| Rate for Payer: Humana Commercial |
$2,892.55
|
| Rate for Payer: Humana KY Medicaid |
$1,170.29
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,182.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,790.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,511.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,193.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,994.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,552.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,054.93
|
| Rate for Payer: PHCS Commercial |
$3,266.88
|
| Rate for Payer: United Healthcare All Payer |
$2,994.64
|
|
|
CT ANGIO ABDOMINAL ARTERIES
|
Facility
|
IP
|
$3,403.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
35000013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$442.39 |
| Max. Negotiated Rate |
$3,266.88 |
| Rate for Payer: Aetna Commercial |
$2,620.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,654.34
|
| Rate for Payer: Cash Price |
$1,701.50
|
| Rate for Payer: Cigna Commercial |
$2,824.49
|
| Rate for Payer: First Health Commercial |
$3,232.85
|
| Rate for Payer: Humana Commercial |
$2,892.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,790.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,511.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,020.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,994.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,552.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,054.93
|
| Rate for Payer: PHCS Commercial |
$3,266.88
|
| Rate for Payer: United Healthcare All Payer |
$2,994.64
|
|
