|
CT HEAD ORBIT FACIAL W/O
|
Professional
|
Both
|
$2,492.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
35000025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$81.31 |
| Max. Negotiated Rate |
$2,492.00 |
| Rate for Payer: Aetna Commercial |
$394.97
|
| Rate for Payer: Anthem Medicaid |
$182.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,492.00
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cigna Commercial |
$408.61
|
| Rate for Payer: Healthspan PPO |
$271.40
|
| Rate for Payer: Humana Medicaid |
$182.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$81.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$186.44
|
| Rate for Payer: Molina Healthcare Passport |
$182.78
|
| Rate for Payer: Multiplan PHCS |
$1,495.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,744.40
|
| Rate for Payer: UHCCP Medicaid |
$872.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$184.61
|
|
|
CT HEAD ORBIT FACIAL W/O
|
Facility
|
IP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
35000025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$323.96 |
| Max. Negotiated Rate |
$2,392.32 |
| Rate for Payer: Aetna Commercial |
$1,918.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,943.76
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cigna Commercial |
$2,068.36
|
| Rate for Payer: First Health Commercial |
$2,367.40
|
| Rate for Payer: Humana Commercial |
$2,118.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,043.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,839.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$747.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,192.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$323.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.52
|
| Rate for Payer: PHCS Commercial |
$2,392.32
|
| Rate for Payer: United Healthcare All Payer |
$2,192.96
|
|
|
CT HEAD ORBIT FACIAL W/O
|
Facility
|
OP
|
$2,492.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
35000025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$2,392.32 |
| Rate for Payer: Aetna Commercial |
$1,918.84
|
| Rate for Payer: Anthem Medicaid |
$857.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,943.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cash Price |
$1,246.00
|
| Rate for Payer: Cigna Commercial |
$2,068.36
|
| Rate for Payer: First Health Commercial |
$2,367.40
|
| Rate for Payer: Humana Commercial |
$2,118.20
|
| Rate for Payer: Humana KY Medicaid |
$857.00
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$865.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,043.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,839.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$874.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,192.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$323.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$772.52
|
| Rate for Payer: PHCS Commercial |
$2,392.32
|
| Rate for Payer: United Healthcare All Payer |
$2,192.96
|
|
|
CT HEAD ORBIT FACIAL W/O(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
350P0025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$81.31 |
| Max. Negotiated Rate |
$408.61 |
| Rate for Payer: Aetna Commercial |
$394.97
|
| Rate for Payer: Anthem Medicaid |
$182.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$408.61
|
| Rate for Payer: Healthspan PPO |
$271.40
|
| Rate for Payer: Humana Medicaid |
$182.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$81.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$186.44
|
| Rate for Payer: Molina Healthcare Passport |
$182.78
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$184.61
|
|
|
CT HEAD ORBIT FACIAL W/O(T
|
Facility
|
IP
|
$2,242.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
350T0025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$291.46 |
| Max. Negotiated Rate |
$2,152.32 |
| Rate for Payer: Aetna Commercial |
$1,726.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,748.76
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cigna Commercial |
$1,860.86
|
| Rate for Payer: First Health Commercial |
$2,129.90
|
| Rate for Payer: Humana Commercial |
$1,905.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,838.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,654.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$672.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,972.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,681.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$695.02
|
| Rate for Payer: PHCS Commercial |
$2,152.32
|
| Rate for Payer: United Healthcare All Payer |
$1,972.96
|
|
|
CT HEAD ORBIT FACIAL W/O(T
|
Facility
|
OP
|
$2,242.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
350T0025
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$2,152.32 |
| Rate for Payer: Aetna Commercial |
$1,726.34
|
| Rate for Payer: Anthem Medicaid |
$771.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,748.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cigna Commercial |
$1,860.86
|
| Rate for Payer: First Health Commercial |
$2,129.90
|
| Rate for Payer: Humana Commercial |
$1,905.70
|
| Rate for Payer: Humana KY Medicaid |
$771.02
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$778.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,838.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,654.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$786.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,972.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,681.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$695.02
|
| Rate for Payer: PHCS Commercial |
$2,152.32
|
| Rate for Payer: United Healthcare All Payer |
$1,972.96
|
|
|
CT HRT C+ STRUX CGEN HRT DS
|
Facility
|
IP
|
$2,182.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
35000094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$283.66 |
| Max. Negotiated Rate |
$2,094.72 |
| Rate for Payer: Aetna Commercial |
$1,680.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,701.96
|
| Rate for Payer: Cash Price |
$1,091.00
|
| Rate for Payer: Cigna Commercial |
$1,811.06
|
| Rate for Payer: First Health Commercial |
$2,072.90
|
| Rate for Payer: Humana Commercial |
$1,854.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,789.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,610.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$654.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,920.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,636.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$676.42
|
| Rate for Payer: PHCS Commercial |
$2,094.72
|
| Rate for Payer: United Healthcare All Payer |
$1,920.16
|
|
|
CT HRT C+ STRUX CGEN HRT DS
|
Professional
|
Both
|
$2,182.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
35000094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$156.09 |
| Max. Negotiated Rate |
$2,182.00 |
| Rate for Payer: Aetna Commercial |
$566.42
|
| Rate for Payer: Anthem Medicaid |
$272.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,182.00
|
| Rate for Payer: Cash Price |
$1,091.00
|
| Rate for Payer: Cash Price |
$1,091.00
|
| Rate for Payer: Cigna Commercial |
$581.88
|
| Rate for Payer: Healthspan PPO |
$305.83
|
| Rate for Payer: Humana Medicaid |
$272.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$277.81
|
| Rate for Payer: Molina Healthcare Passport |
$272.36
|
| Rate for Payer: Multiplan PHCS |
$1,309.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,527.40
|
| Rate for Payer: UHCCP Medicaid |
$763.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$275.08
|
|
|
CT HRT C+ STRUX CGEN HRT DS
|
Facility
|
OP
|
$2,182.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
35000094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$2,094.72 |
| Rate for Payer: Aetna Commercial |
$1,680.14
|
| Rate for Payer: Anthem Medicaid |
$750.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,701.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,091.00
|
| Rate for Payer: Cash Price |
$1,091.00
|
| Rate for Payer: Cigna Commercial |
$1,811.06
|
| Rate for Payer: First Health Commercial |
$2,072.90
|
| Rate for Payer: Humana Commercial |
$1,854.70
|
| Rate for Payer: Humana KY Medicaid |
$750.39
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$758.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,789.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,610.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$765.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,920.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,636.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$676.42
|
| Rate for Payer: PHCS Commercial |
$2,094.72
|
| Rate for Payer: United Healthcare All Payer |
$1,920.16
|
|
|
CT HRT C+ STRUX CGEN HRT DS (P
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
350P0094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$581.88 |
| Rate for Payer: Aetna Commercial |
$566.42
|
| Rate for Payer: Anthem Medicaid |
$272.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$145.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$581.88
|
| Rate for Payer: Healthspan PPO |
$305.83
|
| Rate for Payer: Humana Medicaid |
$272.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$277.81
|
| Rate for Payer: Molina Healthcare Passport |
$272.36
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.50
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$275.08
|
|
|
CT HRT C+ STRUX CGEN HRT DS (T
|
Facility
|
OP
|
$2,037.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
350T0094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$1,955.52 |
| Rate for Payer: Aetna Commercial |
$1,568.49
|
| Rate for Payer: Anthem Medicaid |
$700.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,588.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,018.50
|
| Rate for Payer: Cash Price |
$1,018.50
|
| Rate for Payer: Cigna Commercial |
$1,690.71
|
| Rate for Payer: First Health Commercial |
$1,935.15
|
| Rate for Payer: Humana Commercial |
$1,731.45
|
| Rate for Payer: Humana KY Medicaid |
$700.52
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$707.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,670.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,503.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$714.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,792.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,527.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$631.47
|
| Rate for Payer: PHCS Commercial |
$1,955.52
|
| Rate for Payer: United Healthcare All Payer |
$1,792.56
|
|
|
CT HRT C+ STRUX CGEN HRT DS (T
|
Facility
|
IP
|
$2,037.00
|
|
|
Service Code
|
HCPCS 75573
|
| Hospital Charge Code |
350T0094
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$264.81 |
| Max. Negotiated Rate |
$1,955.52 |
| Rate for Payer: Aetna Commercial |
$1,568.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,588.86
|
| Rate for Payer: Cash Price |
$1,018.50
|
| Rate for Payer: Cigna Commercial |
$1,690.71
|
| Rate for Payer: First Health Commercial |
$1,935.15
|
| Rate for Payer: Humana Commercial |
$1,731.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,670.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,503.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$611.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,792.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,527.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$631.47
|
| Rate for Payer: PHCS Commercial |
$1,955.52
|
| Rate for Payer: United Healthcare All Payer |
$1,792.56
|
|
|
CT HRT W/3D IMAGE
|
Facility
|
OP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
35000012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem Medicaid |
$1,038.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Humana KY Medicaid |
$1,038.58
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,049.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,059.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
CT HRT W/3D IMAGE
|
Professional
|
Both
|
$3,020.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
35000012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$106.46 |
| Max. Negotiated Rate |
$3,020.00 |
| Rate for Payer: Aetna Commercial |
$398.64
|
| Rate for Payer: Anthem Medicaid |
$191.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,020.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$409.47
|
| Rate for Payer: Healthspan PPO |
$215.12
|
| Rate for Payer: Humana Medicaid |
$191.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$106.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.39
|
| Rate for Payer: Molina Healthcare Passport |
$191.56
|
| Rate for Payer: Multiplan PHCS |
$1,812.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,114.00
|
| Rate for Payer: UHCCP Medicaid |
$1,057.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.48
|
|
|
CT HRT W/3D IMAGE
|
Facility
|
IP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
35000012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$392.60 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$906.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
CT HRT W/3D IMAGE(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
350P0012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$409.47 |
| Rate for Payer: Aetna Commercial |
$398.64
|
| Rate for Payer: Anthem Medicaid |
$191.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$409.47
|
| Rate for Payer: Healthspan PPO |
$215.12
|
| Rate for Payer: Humana Medicaid |
$191.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$106.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.39
|
| Rate for Payer: Molina Healthcare Passport |
$191.56
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.48
|
|
|
CT HRT W/3D IMAGE(T
|
Facility
|
IP
|
$2,895.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
350T0012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$376.35 |
| Max. Negotiated Rate |
$2,779.20 |
| Rate for Payer: Aetna Commercial |
$2,229.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,258.10
|
| Rate for Payer: Cash Price |
$1,447.50
|
| Rate for Payer: Cigna Commercial |
$2,402.85
|
| Rate for Payer: First Health Commercial |
$2,750.25
|
| Rate for Payer: Humana Commercial |
$2,460.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.45
|
| Rate for Payer: PHCS Commercial |
$2,779.20
|
| Rate for Payer: United Healthcare All Payer |
$2,547.60
|
|
|
CT HRT W/3D IMAGE(T
|
Facility
|
OP
|
$2,895.00
|
|
|
Service Code
|
HCPCS 75572
|
| Hospital Charge Code |
350T0012
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$2,779.20 |
| Rate for Payer: Aetna Commercial |
$2,229.15
|
| Rate for Payer: Anthem Medicaid |
$995.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,258.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,447.50
|
| Rate for Payer: Cash Price |
$1,447.50
|
| Rate for Payer: Cigna Commercial |
$2,402.85
|
| Rate for Payer: First Health Commercial |
$2,750.25
|
| Rate for Payer: Humana Commercial |
$2,460.75
|
| Rate for Payer: Humana KY Medicaid |
$995.59
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,005.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,015.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.45
|
| Rate for Payer: PHCS Commercial |
$2,779.20
|
| Rate for Payer: United Healthcare All Payer |
$2,547.60
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
761T0332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.78 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.86
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
761P0332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$62.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.40
|
| Rate for Payer: Anthem Medicaid |
$30.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$62.92
|
| Rate for Payer: Healthspan PPO |
$164.01
|
| Rate for Payer: Humana Medicaid |
$30.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$31.45
|
| Rate for Payer: Molina Healthcare Passport |
$30.83
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$30.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.14
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Facility
|
IP
|
$1,106.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
76100332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.78 |
| Max. Negotiated Rate |
$1,061.76 |
| Rate for Payer: Aetna Commercial |
$851.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$862.68
|
| Rate for Payer: Cash Price |
$553.00
|
| Rate for Payer: Cigna Commercial |
$917.98
|
| Rate for Payer: First Health Commercial |
$1,050.70
|
| Rate for Payer: Humana Commercial |
$940.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$906.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$816.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$973.28
|
| Rate for Payer: Ohio Health Group HMO |
$829.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$221.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.86
|
| Rate for Payer: PHCS Commercial |
$1,061.76
|
| Rate for Payer: United Healthcare All Payer |
$973.28
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
761T0332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.78 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem Medicaid |
$174.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Humana KY Medicaid |
$174.01
|
| Rate for Payer: Kentucky WC Medicaid |
$175.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$101.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.86
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Facility
|
OP
|
$1,106.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
76100332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.78 |
| Max. Negotiated Rate |
$1,061.76 |
| Rate for Payer: Aetna Commercial |
$851.62
|
| Rate for Payer: Anthem Medicaid |
$380.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$862.68
|
| Rate for Payer: Cash Price |
$553.00
|
| Rate for Payer: Cigna Commercial |
$917.98
|
| Rate for Payer: First Health Commercial |
$1,050.70
|
| Rate for Payer: Humana Commercial |
$940.10
|
| Rate for Payer: Humana KY Medicaid |
$380.35
|
| Rate for Payer: Kentucky WC Medicaid |
$384.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$906.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$816.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$973.28
|
| Rate for Payer: Ohio Health Group HMO |
$829.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$221.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.86
|
| Rate for Payer: PHCS Commercial |
$1,061.76
|
| Rate for Payer: United Healthcare All Payer |
$973.28
|
|
|
CT INJ OF SINUS TRACT SINOGRAM
|
Professional
|
Both
|
$1,106.00
|
|
|
Service Code
|
HCPCS 20501
|
| Hospital Charge Code |
76100332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$1,106.00 |
| Rate for Payer: Aetna Commercial |
$62.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.40
|
| Rate for Payer: Anthem Medicaid |
$30.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,106.00
|
| Rate for Payer: Cash Price |
$553.00
|
| Rate for Payer: Cash Price |
$553.00
|
| Rate for Payer: Cigna Commercial |
$62.92
|
| Rate for Payer: Healthspan PPO |
$164.01
|
| Rate for Payer: Humana Medicaid |
$30.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$31.45
|
| Rate for Payer: Molina Healthcare Passport |
$30.83
|
| Rate for Payer: Multiplan PHCS |
$663.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$774.20
|
| Rate for Payer: UHCCP Medicaid |
$30.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$31.14
|
|
|
CT INNER EAR W/CONTRAST
|
Professional
|
Both
|
$2,679.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
35000026
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$87.85 |
| Max. Negotiated Rate |
$2,679.00 |
| Rate for Payer: Aetna Commercial |
$572.89
|
| Rate for Payer: Anthem Medicaid |
$212.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,679.00
|
| Rate for Payer: Cash Price |
$1,339.50
|
| Rate for Payer: Cash Price |
$1,339.50
|
| Rate for Payer: Cigna Commercial |
$476.86
|
| Rate for Payer: Healthspan PPO |
$393.66
|
| Rate for Payer: Humana Medicaid |
$212.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$216.36
|
| Rate for Payer: Molina Healthcare Passport |
$212.12
|
| Rate for Payer: Multiplan PHCS |
$1,607.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,875.30
|
| Rate for Payer: UHCCP Medicaid |
$937.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$214.24
|
|
