|
CT ABD & PELV 1/> REGNS
|
Facility
|
IP
|
$5,796.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
35000064
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,738.80 |
| Max. Negotiated Rate |
$5,564.16 |
| Rate for Payer: Aetna Commercial |
$4,462.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,520.88
|
| Rate for Payer: Cash Price |
$2,898.00
|
| Rate for Payer: Cigna Commercial |
$4,810.68
|
| Rate for Payer: First Health Commercial |
$5,506.20
|
| Rate for Payer: Humana Commercial |
$4,926.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,752.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,277.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,738.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,100.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,347.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,636.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,042.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,999.24
|
| Rate for Payer: PHCS Commercial |
$5,564.16
|
| Rate for Payer: United Healthcare All Payer |
$5,100.48
|
|
|
CT ABD & PELV 1/> REGNS(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
350P0064
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$706.69 |
| Rate for Payer: Aetna Commercial |
$668.41
|
| Rate for Payer: Ambetter Exchange |
$309.52
|
| Rate for Payer: Anthem Medicaid |
$375.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$309.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$309.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$371.42
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$706.69
|
| Rate for Payer: Healthspan PPO |
$346.20
|
| Rate for Payer: Humana Medicaid |
$375.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$125.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$309.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$383.44
|
| Rate for Payer: Molina Healthcare Passport |
$375.92
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.38
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$309.52
|
|
|
CT ABD & PELV 1/> REGNS(T
|
Facility
|
OP
|
$5,571.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
350T0064
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$5,348.16 |
| Rate for Payer: Aetna Commercial |
$4,289.67
|
| Rate for Payer: Anthem Medicaid |
$1,915.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,345.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$2,785.50
|
| Rate for Payer: Cash Price |
$2,785.50
|
| Rate for Payer: Cigna Commercial |
$4,623.93
|
| Rate for Payer: First Health Commercial |
$5,292.45
|
| Rate for Payer: Humana Commercial |
$4,735.35
|
| Rate for Payer: Humana KY Medicaid |
$1,915.87
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,935.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,568.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,954.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,178.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,456.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,846.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,843.99
|
| Rate for Payer: PHCS Commercial |
$5,348.16
|
| Rate for Payer: United Healthcare All Payer |
$4,902.48
|
|
|
CT ABD & PELV 1/> REGNS(T
|
Facility
|
IP
|
$5,571.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
350T0064
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,671.30 |
| Max. Negotiated Rate |
$5,348.16 |
| Rate for Payer: Aetna Commercial |
$4,289.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,345.38
|
| Rate for Payer: Cash Price |
$2,785.50
|
| Rate for Payer: Cigna Commercial |
$4,623.93
|
| Rate for Payer: First Health Commercial |
$5,292.45
|
| Rate for Payer: Humana Commercial |
$4,735.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,568.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,178.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,456.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,846.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,843.99
|
| Rate for Payer: PHCS Commercial |
$5,348.16
|
| Rate for Payer: United Healthcare All Payer |
$4,902.48
|
|
|
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: Ambetter Exchange |
$170.13
|
| Rate for Payer: Anthem Medicaid |
$189.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$170.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$170.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$204.16
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$170.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.13
|
| 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 |
$221.17
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$170.13
|
|
|
CT ABD & PELVIS W/O CONTRAS(T
|
Facility
|
IP
|
$4,778.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
350T0062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,433.40 |
| Max. Negotiated Rate |
$4,586.88 |
| Rate for Payer: Aetna Commercial |
$3,679.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,726.84
|
| Rate for Payer: Cash Price |
$2,389.00
|
| Rate for Payer: Cigna Commercial |
$3,965.74
|
| Rate for Payer: First Health Commercial |
$4,539.10
|
| Rate for Payer: Humana Commercial |
$4,061.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,917.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,526.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,433.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,204.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,583.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,822.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,156.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,296.82
|
| Rate for Payer: PHCS Commercial |
$4,586.88
|
| Rate for Payer: United Healthcare All Payer |
$4,204.64
|
|
|
CT ABD & PELVIS W/O CONTRAS(T
|
Facility
|
OP
|
$4,778.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
350T0062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$4,586.88 |
| Rate for Payer: Aetna Commercial |
$3,679.06
|
| Rate for Payer: Anthem Medicaid |
$1,643.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,726.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$2,389.00
|
| Rate for Payer: Cash Price |
$2,389.00
|
| Rate for Payer: Cigna Commercial |
$3,965.74
|
| Rate for Payer: First Health Commercial |
$4,539.10
|
| Rate for Payer: Humana Commercial |
$4,061.30
|
| Rate for Payer: Humana KY Medicaid |
$1,643.15
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,659.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,917.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,526.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,676.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,204.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,583.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,822.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,156.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,296.82
|
| Rate for Payer: PHCS Commercial |
$4,586.88
|
| Rate for Payer: United Healthcare All Payer |
$4,204.64
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Facility
|
OP
|
$4,953.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$4,754.88 |
| Rate for Payer: Aetna Commercial |
$3,813.81
|
| Rate for Payer: Anthem Medicaid |
$1,703.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,863.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$2,476.50
|
| Rate for Payer: Cash Price |
$2,476.50
|
| Rate for Payer: Cigna Commercial |
$4,110.99
|
| Rate for Payer: First Health Commercial |
$4,705.35
|
| Rate for Payer: Humana Commercial |
$4,210.05
|
| Rate for Payer: Humana KY Medicaid |
$1,703.34
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,720.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,061.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,655.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,737.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,358.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,714.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,962.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,309.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,417.57
|
| Rate for Payer: PHCS Commercial |
$4,754.88
|
| Rate for Payer: United Healthcare All Payer |
$4,358.64
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Facility
|
IP
|
$4,953.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,485.90 |
| Max. Negotiated Rate |
$4,754.88 |
| Rate for Payer: Aetna Commercial |
$3,813.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,863.34
|
| Rate for Payer: Cash Price |
$2,476.50
|
| Rate for Payer: Cigna Commercial |
$4,110.99
|
| Rate for Payer: First Health Commercial |
$4,705.35
|
| Rate for Payer: Humana Commercial |
$4,210.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,061.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,655.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,485.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,358.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,714.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,962.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,309.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,417.57
|
| Rate for Payer: PHCS Commercial |
$4,754.88
|
| Rate for Payer: United Healthcare All Payer |
$4,358.64
|
|
|
CT ABD & PELVIS W/O CONTRAST
|
Professional
|
Both
|
$4,953.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
35000062
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$107.86 |
| Max. Negotiated Rate |
$2,971.80 |
| Rate for Payer: Aetna Commercial |
$338.25
|
| Rate for Payer: Ambetter Exchange |
$170.13
|
| Rate for Payer: Anthem Medicaid |
$189.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$170.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$170.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$204.16
|
| Rate for Payer: Cash Price |
$2,476.50
|
| Rate for Payer: Cash Price |
$2,476.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$170.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.78
|
| Rate for Payer: Molina Healthcare Passport |
$189.00
|
| Rate for Payer: Multiplan PHCS |
$2,971.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$221.17
|
| Rate for Payer: UHCCP Medicaid |
$1,733.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$170.13
|
|
|
CT ABD & PELV W/CONTRAST
|
Facility
|
IP
|
$5,335.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,600.50 |
| Max. Negotiated Rate |
$5,121.60 |
| Rate for Payer: Aetna Commercial |
$4,107.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,161.30
|
| Rate for Payer: Cash Price |
$2,667.50
|
| Rate for Payer: Cigna Commercial |
$4,428.05
|
| Rate for Payer: First Health Commercial |
$5,068.25
|
| Rate for Payer: Humana Commercial |
$4,534.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,374.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,937.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,600.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,694.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,641.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,681.15
|
| Rate for Payer: PHCS Commercial |
$5,121.60
|
| Rate for Payer: United Healthcare All Payer |
$4,694.80
|
|
|
CT ABD & PELV W/CONTRAST
|
Facility
|
OP
|
$5,335.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$5,121.60 |
| Rate for Payer: Aetna Commercial |
$4,107.95
|
| Rate for Payer: Anthem Medicaid |
$1,834.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,161.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$2,667.50
|
| Rate for Payer: Cash Price |
$2,667.50
|
| Rate for Payer: Cigna Commercial |
$4,428.05
|
| Rate for Payer: First Health Commercial |
$5,068.25
|
| Rate for Payer: Humana Commercial |
$4,534.75
|
| Rate for Payer: Humana KY Medicaid |
$1,834.71
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,853.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,374.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,937.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,871.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,694.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,641.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,681.15
|
| Rate for Payer: PHCS Commercial |
$5,121.60
|
| Rate for Payer: United Healthcare All Payer |
$4,694.80
|
|
|
CT ABD & PELV W/CONTRAST
|
Professional
|
Both
|
$5,335.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
35000063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$113.01 |
| Max. Negotiated Rate |
$3,201.00 |
| Rate for Payer: Aetna Commercial |
$528.69
|
| Rate for Payer: Ambetter Exchange |
$276.52
|
| Rate for Payer: Anthem Medicaid |
$297.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.82
|
| Rate for Payer: Cash Price |
$2,667.50
|
| Rate for Payer: Cash Price |
$2,667.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$276.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$302.94
|
| Rate for Payer: Molina Healthcare Passport |
$297.00
|
| Rate for Payer: Multiplan PHCS |
$3,201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$359.48
|
| Rate for Payer: UHCCP Medicaid |
$1,867.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.52
|
|
|
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: Ambetter Exchange |
$276.52
|
| Rate for Payer: Anthem Medicaid |
$297.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.82
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$276.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.52
|
| 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 |
$359.48
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.52
|
|
|
CT ABD & PELV W/CONTRAST(T
|
Facility
|
IP
|
$5,160.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
350T0063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,548.00 |
| Max. Negotiated Rate |
$4,953.60 |
| Rate for Payer: Aetna Commercial |
$3,973.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,024.80
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cigna Commercial |
$4,282.80
|
| Rate for Payer: First Health Commercial |
$4,902.00
|
| Rate for Payer: Humana Commercial |
$4,386.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,231.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,808.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,540.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,489.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,560.40
|
| Rate for Payer: PHCS Commercial |
$4,953.60
|
| Rate for Payer: United Healthcare All Payer |
$4,540.80
|
|
|
CT ABD & PELV W/CONTRAST(T
|
Facility
|
OP
|
$5,160.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
350T0063
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$4,953.60 |
| Rate for Payer: Aetna Commercial |
$3,973.20
|
| Rate for Payer: Anthem Medicaid |
$1,774.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,024.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Cigna Commercial |
$4,282.80
|
| Rate for Payer: First Health Commercial |
$4,902.00
|
| Rate for Payer: Humana Commercial |
$4,386.00
|
| Rate for Payer: Humana KY Medicaid |
$1,774.52
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,792.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,231.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,808.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,810.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,540.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,489.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,560.40
|
| Rate for Payer: PHCS Commercial |
$4,953.60
|
| Rate for Payer: United Healthcare All Payer |
$4,540.80
|
|
|
CTA BRAIN PERFUSION
|
Facility
|
IP
|
$1,783.00
|
|
|
Service Code
|
HCPCS 0042T
|
| Hospital Charge Code |
35000033
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$534.90 |
| 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 |
$1,426.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,551.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.27
|
| 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 |
$534.90 |
| 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 |
$1,426.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,551.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.27
|
| Rate for Payer: PHCS Commercial |
$1,711.68
|
| Rate for Payer: United Healthcare All Payer |
$1,569.04
|
|
|
CTA CIRCLE OF WILLIS
|
Professional
|
Both
|
$3,556.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$111.63 |
| Max. Negotiated Rate |
$2,133.60 |
| Rate for Payer: Aetna Commercial |
$670.94
|
| Rate for Payer: Ambetter Exchange |
$253.59
|
| Rate for Payer: Anthem Medicaid |
$262.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$253.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$253.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$304.31
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cash Price |
$1,778.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$253.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$268.13
|
| Rate for Payer: Molina Healthcare Passport |
$262.87
|
| Rate for Payer: Multiplan PHCS |
$2,133.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$329.67
|
| Rate for Payer: UHCCP Medicaid |
$1,244.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$265.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$253.59
|
|
|
CTA CIRCLE OF WILLIS
|
Facility
|
OP
|
$3,556.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$3,413.76 |
| Rate for Payer: Aetna Commercial |
$2,738.12
|
| Rate for Payer: Anthem Medicaid |
$1,222.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,773.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cigna Commercial |
$2,951.48
|
| Rate for Payer: First Health Commercial |
$3,378.20
|
| Rate for Payer: Humana Commercial |
$3,022.60
|
| Rate for Payer: Humana KY Medicaid |
$1,222.91
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,235.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,915.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,624.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,247.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,129.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,667.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,844.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,093.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,453.64
|
| Rate for Payer: PHCS Commercial |
$3,413.76
|
| Rate for Payer: United Healthcare All Payer |
$3,129.28
|
|
|
CTA CIRCLE OF WILLIS
|
Facility
|
IP
|
$3,556.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
35000031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,066.80 |
| Max. Negotiated Rate |
$3,413.76 |
| Rate for Payer: Aetna Commercial |
$2,738.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,773.68
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cigna Commercial |
$2,951.48
|
| Rate for Payer: First Health Commercial |
$3,378.20
|
| Rate for Payer: Humana Commercial |
$3,022.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,915.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,624.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,066.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,129.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,667.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,844.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,093.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,453.64
|
| Rate for Payer: PHCS Commercial |
$3,413.76
|
| Rate for Payer: United Healthcare All Payer |
$3,129.28
|
|
|
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: Ambetter Exchange |
$253.59
|
| Rate for Payer: Anthem Medicaid |
$262.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$253.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$253.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$304.31
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$253.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.59
|
| 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 |
$329.67
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$265.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$253.59
|
|
|
CTA CIRCLE OF WILLIS(T
|
Facility
|
OP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
350T0031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$3,197.76 |
| Rate for Payer: Aetna Commercial |
$2,564.87
|
| Rate for Payer: Anthem Medicaid |
$1,145.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,598.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,665.50
|
| Rate for Payer: Cash Price |
$1,665.50
|
| Rate for Payer: Cigna Commercial |
$2,764.73
|
| Rate for Payer: First Health Commercial |
$3,164.45
|
| Rate for Payer: Humana Commercial |
$2,831.35
|
| Rate for Payer: Humana KY Medicaid |
$1,145.53
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,157.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,731.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,458.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,168.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,931.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,498.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,664.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,897.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.39
|
| Rate for Payer: PHCS Commercial |
$3,197.76
|
| Rate for Payer: United Healthcare All Payer |
$2,931.28
|
|
|
CTA CIRCLE OF WILLIS(T
|
Facility
|
IP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
350T0031
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$999.30 |
| Max. Negotiated Rate |
$3,197.76 |
| Rate for Payer: Aetna Commercial |
$2,564.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,598.18
|
| Rate for Payer: Cash Price |
$1,665.50
|
| Rate for Payer: Cigna Commercial |
$2,764.73
|
| Rate for Payer: First Health Commercial |
$3,164.45
|
| Rate for Payer: Humana Commercial |
$2,831.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,731.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,458.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$999.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,931.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,498.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,664.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,897.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.39
|
| Rate for Payer: PHCS Commercial |
$3,197.76
|
| Rate for Payer: United Healthcare All Payer |
$2,931.28
|
|
|
[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 |
$18.62 |
| 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 |
$46.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.82
|
| Rate for Payer: PHCS Commercial |
$59.58
|
| Rate for Payer: United Healthcare All Payer |
$54.61
|
|
