|
CY PREP CONCENTRATE TECHNIQ
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$34.15 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$219.45
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: Cigna Commercial |
$236.55
|
| Rate for Payer: First Health Commercial |
$270.75
|
| Rate for Payer: Humana Commercial |
$242.25
|
| Rate for Payer: Humana KY Medicaid |
$34.15
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$34.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$233.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$210.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$250.80
|
| Rate for Payer: Ohio Health Group HMO |
$213.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.35
|
| Rate for Payer: PHCS Commercial |
$273.60
|
| Rate for Payer: United Healthcare All Payer |
$250.80
|
|
|
CY PREP CONCENTRATE TECHNIQ
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$290.00 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Humana Medicaid |
$34.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.83
|
| Rate for Payer: Molina Healthcare Passport |
$34.15
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.00
|
| Rate for Payer: UHCCP Medicaid |
$101.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
|
|
CY PREP CONCENTRATE TECHNIQ
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30002033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$37.05 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$219.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$228.86
|
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: Cigna Commercial |
$236.55
|
| Rate for Payer: First Health Commercial |
$270.75
|
| Rate for Payer: Humana Commercial |
$242.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$233.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$210.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$85.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$250.80
|
| Rate for Payer: Ohio Health Group HMO |
$213.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.35
|
| Rate for Payer: PHCS Commercial |
$273.60
|
| Rate for Payer: United Healthcare All Payer |
$250.80
|
|
|
CY PREP CONCENTRATE TECHNIQ (P
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300P2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$109.03 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Humana Medicaid |
$34.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.83
|
| Rate for Payer: Molina Healthcare Passport |
$34.15
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
|
|
CY PREP CONCENTRATE TECHNIQ (T
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300T2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$31.72 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.93
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.64
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
CY PREP CONCENTRATE TECHNIQ (T
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
300T2033
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$31.72 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Humana KY Medicaid |
$34.15
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$34.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.64
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Humana KY Medicaid |
$34.15
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$34.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.40
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$109.03
|
| Rate for Payer: Anthem Medicaid |
$34.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$240.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$44.28
|
| Rate for Payer: Healthspan PPO |
$103.53
|
| Rate for Payer: Humana Medicaid |
$34.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.83
|
| Rate for Payer: Molina Healthcare Passport |
$34.15
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$168.00
|
| Rate for Payer: UHCCP Medicaid |
$84.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.49
|
|
|
CY PREP CONCENTRATION TECHNIQ
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
30001417
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.72
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.40
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
CYRAMZA 5MG (100MG/10ML)VIAL
|
Facility
|
IP
|
$7,939.51
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,032.14 |
| Max. Negotiated Rate |
$7,621.93 |
| Rate for Payer: Aetna Commercial |
$6,113.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,192.82
|
| Rate for Payer: Cash Price |
$3,969.76
|
| Rate for Payer: Cigna Commercial |
$6,589.79
|
| Rate for Payer: First Health Commercial |
$7,542.53
|
| Rate for Payer: Humana Commercial |
$6,748.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,510.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,859.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,381.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,986.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,954.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,587.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,032.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,461.25
|
| Rate for Payer: PHCS Commercial |
$7,621.93
|
| Rate for Payer: United Healthcare All Payer |
$6,986.77
|
|
|
CYRAMZA 5MG (100MG/10ML)VIAL
|
Facility
|
OP
|
$7,939.51
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.24 |
| Max. Negotiated Rate |
$7,621.93 |
| Rate for Payer: Aetna Commercial |
$6,113.42
|
| Rate for Payer: Anthem Medicaid |
$2,730.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$70.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,192.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$98.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.83
|
| Rate for Payer: Cash Price |
$3,969.76
|
| Rate for Payer: Cash Price |
$3,969.76
|
| Rate for Payer: Cigna Commercial |
$6,589.79
|
| Rate for Payer: First Health Commercial |
$7,542.53
|
| Rate for Payer: Humana Commercial |
$6,748.58
|
| Rate for Payer: Humana KY Medicaid |
$2,730.40
|
| Rate for Payer: Humana Medicare Advantage |
$70.24
|
| Rate for Payer: Kentucky WC Medicaid |
$2,758.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,510.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,859.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,785.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,986.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,954.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,587.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,032.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,461.25
|
| Rate for Payer: PHCS Commercial |
$7,621.93
|
| Rate for Payer: United Healthcare All Payer |
$6,986.77
|
|
|
CYRAMZA 5MG [500 MG/50ML)VIAL
|
Facility
|
OP
|
$39,697.53
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.24 |
| Max. Negotiated Rate |
$38,109.63 |
| Rate for Payer: Aetna Commercial |
$30,567.10
|
| Rate for Payer: Anthem Medicaid |
$13,651.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$70.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,964.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$98.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.83
|
| Rate for Payer: Cash Price |
$19,848.76
|
| Rate for Payer: Cash Price |
$19,848.76
|
| Rate for Payer: Cigna Commercial |
$32,948.95
|
| Rate for Payer: First Health Commercial |
$37,712.65
|
| Rate for Payer: Humana Commercial |
$33,742.90
|
| Rate for Payer: Humana KY Medicaid |
$13,651.98
|
| Rate for Payer: Humana Medicare Advantage |
$70.24
|
| Rate for Payer: Kentucky WC Medicaid |
$13,790.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,551.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,296.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,925.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,933.83
|
| Rate for Payer: Ohio Health Group HMO |
$29,773.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,939.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,160.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,306.23
|
| Rate for Payer: PHCS Commercial |
$38,109.63
|
| Rate for Payer: United Healthcare All Payer |
$34,933.83
|
|
|
CYRAMZA 5MG [500 MG/50ML)VIAL
|
Facility
|
IP
|
$39,697.53
|
|
|
Service Code
|
HCPCS J9308
|
| Hospital Charge Code |
25002674
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,160.68 |
| Max. Negotiated Rate |
$38,109.63 |
| Rate for Payer: Aetna Commercial |
$30,567.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,964.07
|
| Rate for Payer: Cash Price |
$19,848.76
|
| Rate for Payer: Cigna Commercial |
$32,948.95
|
| Rate for Payer: First Health Commercial |
$37,712.65
|
| Rate for Payer: Humana Commercial |
$33,742.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,551.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,296.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,909.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,933.83
|
| Rate for Payer: Ohio Health Group HMO |
$29,773.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,939.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,160.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,306.23
|
| Rate for Payer: PHCS Commercial |
$38,109.63
|
| Rate for Payer: United Healthcare All Payer |
$34,933.83
|
|
|
CYST ASPIRATION EA ADDTL
|
Facility
|
IP
|
$568.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.84 |
| Max. Negotiated Rate |
$545.28 |
| Rate for Payer: Aetna Commercial |
$437.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$443.04
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cigna Commercial |
$471.44
|
| Rate for Payer: First Health Commercial |
$539.60
|
| Rate for Payer: Humana Commercial |
$482.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$465.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$419.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$499.84
|
| Rate for Payer: Ohio Health Group HMO |
$426.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.08
|
| Rate for Payer: PHCS Commercial |
$545.28
|
| Rate for Payer: United Healthcare All Payer |
$499.84
|
|
|
CYST ASPIRATION EA ADDTL
|
Professional
|
Both
|
$568.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna Commercial |
$35.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.21
|
| Rate for Payer: Anthem Medicaid |
$16.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$568.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cigna Commercial |
$38.48
|
| Rate for Payer: Healthspan PPO |
$32.79
|
| Rate for Payer: Humana Medicaid |
$16.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.10
|
| Rate for Payer: Molina Healthcare Passport |
$16.76
|
| Rate for Payer: Multiplan PHCS |
$340.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$397.60
|
| Rate for Payer: UHCCP Medicaid |
$17.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$16.93
|
|
|
CYST ASPIRATION EA ADDTL
|
Facility
|
OP
|
$568.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
76100275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.84 |
| Max. Negotiated Rate |
$545.28 |
| Rate for Payer: Aetna Commercial |
$437.36
|
| Rate for Payer: Anthem Medicaid |
$195.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$443.04
|
| Rate for Payer: Cash Price |
$284.00
|
| Rate for Payer: Cigna Commercial |
$471.44
|
| Rate for Payer: First Health Commercial |
$539.60
|
| Rate for Payer: Humana Commercial |
$482.80
|
| Rate for Payer: Humana KY Medicaid |
$195.34
|
| Rate for Payer: Kentucky WC Medicaid |
$197.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$465.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$419.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$199.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$499.84
|
| Rate for Payer: Ohio Health Group HMO |
$426.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$176.08
|
| Rate for Payer: PHCS Commercial |
$545.28
|
| Rate for Payer: United Healthcare All Payer |
$499.84
|
|
|
CYST ASPIRATION EA ADDTL(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761P0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$35.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$16.21
|
| Rate for Payer: Anthem Medicaid |
$16.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$38.48
|
| Rate for Payer: Healthspan PPO |
$32.79
|
| Rate for Payer: Humana Medicaid |
$16.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.10
|
| Rate for Payer: Molina Healthcare Passport |
$16.76
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$17.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$16.93
|
|
|
CYST ASPIRATION EA ADDTL(T
|
Facility
|
IP
|
$468.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761T0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$449.28 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.04
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$388.44
|
| Rate for Payer: First Health Commercial |
$444.60
|
| Rate for Payer: Humana Commercial |
$397.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.84
|
| Rate for Payer: Ohio Health Group HMO |
$351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.08
|
| Rate for Payer: PHCS Commercial |
$449.28
|
| Rate for Payer: United Healthcare All Payer |
$411.84
|
|
|
CYST ASPIRATION EA ADDTL(T
|
Facility
|
OP
|
$468.00
|
|
|
Service Code
|
HCPCS 19001
|
| Hospital Charge Code |
761T0275
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.84 |
| Max. Negotiated Rate |
$449.28 |
| Rate for Payer: Aetna Commercial |
$360.36
|
| Rate for Payer: Anthem Medicaid |
$160.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.04
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$388.44
|
| Rate for Payer: First Health Commercial |
$444.60
|
| Rate for Payer: Humana Commercial |
$397.80
|
| Rate for Payer: Humana KY Medicaid |
$160.95
|
| Rate for Payer: Kentucky WC Medicaid |
$162.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$383.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$164.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$411.84
|
| Rate for Payer: Ohio Health Group HMO |
$351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.08
|
| Rate for Payer: PHCS Commercial |
$449.28
|
| Rate for Payer: United Healthcare All Payer |
$411.84
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Facility
|
OP
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$181.61 |
| Max. Negotiated Rate |
$1,341.12 |
| Rate for Payer: Aetna Commercial |
$1,075.69
|
| Rate for Payer: Anthem Medicaid |
$480.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,089.66
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$1,159.51
|
| Rate for Payer: First Health Commercial |
$1,327.15
|
| Rate for Payer: Humana Commercial |
$1,187.45
|
| Rate for Payer: Humana KY Medicaid |
$480.43
|
| Rate for Payer: Kentucky WC Medicaid |
$485.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,145.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,030.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$419.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$490.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,229.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,047.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$433.07
|
| Rate for Payer: PHCS Commercial |
$1,341.12
|
| Rate for Payer: United Healthcare All Payer |
$1,229.36
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Professional
|
Both
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$1,397.00 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,397.00
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$838.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$977.90
|
| Rate for Payer: UHCCP Medicaid |
$488.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
|
|
CYST ASPIRATION U/S GUIDANCE
|
Facility
|
IP
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$181.61 |
| Max. Negotiated Rate |
$1,341.12 |
| Rate for Payer: Aetna Commercial |
$1,075.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,089.66
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$1,159.51
|
| Rate for Payer: First Health Commercial |
$1,327.15
|
| Rate for Payer: Humana Commercial |
$1,187.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,145.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,030.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$419.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,229.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,047.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$433.07
|
| Rate for Payer: PHCS Commercial |
$1,341.12
|
| Rate for Payer: United Healthcare All Payer |
$1,229.36
|
|
|
CYST ASPIRATION U/S GUIDANCE(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402P0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$278.08 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
|
|
CYST ASPIRATION U/S GUIDANCE(T
|
Facility
|
OP
|
$1,197.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$155.61 |
| Max. Negotiated Rate |
$1,149.12 |
| Rate for Payer: Aetna Commercial |
$921.69
|
| Rate for Payer: Anthem Medicaid |
$411.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$933.66
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$993.51
|
| Rate for Payer: First Health Commercial |
$1,137.15
|
| Rate for Payer: Humana Commercial |
$1,017.45
|
| Rate for Payer: Humana KY Medicaid |
$411.65
|
| Rate for Payer: Kentucky WC Medicaid |
$415.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$981.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$883.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$419.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,053.36
|
| Rate for Payer: Ohio Health Group HMO |
$897.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.07
|
| Rate for Payer: PHCS Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare All Payer |
$1,053.36
|
|
|
CYST ASPIRATION U/S GUIDANCE(T
|
Facility
|
IP
|
$1,197.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0081
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$155.61 |
| Max. Negotiated Rate |
$1,149.12 |
| Rate for Payer: Aetna Commercial |
$921.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$933.66
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$993.51
|
| Rate for Payer: First Health Commercial |
$1,137.15
|
| Rate for Payer: Humana Commercial |
$1,017.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$981.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$883.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,053.36
|
| Rate for Payer: Ohio Health Group HMO |
$897.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.07
|
| Rate for Payer: PHCS Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare All Payer |
$1,053.36
|
|
