|
[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
|
|
|
CT ANGIO ABDOMINAL ARTERIES
|
Facility
|
IP
|
$3,606.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
35000013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,081.80 |
| Max. Negotiated Rate |
$3,461.76 |
| Rate for Payer: Aetna Commercial |
$2,776.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,812.68
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cigna Commercial |
$2,992.98
|
| Rate for Payer: First Health Commercial |
$3,425.70
|
| Rate for Payer: Humana Commercial |
$3,065.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,956.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,661.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,081.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,173.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,704.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,884.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,137.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,488.14
|
| Rate for Payer: PHCS Commercial |
$3,461.76
|
| Rate for Payer: United Healthcare All Payer |
$3,173.28
|
|
|
CT ANGIO ABDOMINAL ARTERIES
|
Facility
|
OP
|
$3,606.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
35000013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$3,461.76 |
| Rate for Payer: Aetna Commercial |
$2,776.62
|
| Rate for Payer: Anthem Medicaid |
$1,240.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,812.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cigna Commercial |
$2,992.98
|
| Rate for Payer: First Health Commercial |
$3,425.70
|
| Rate for Payer: Humana Commercial |
$3,065.10
|
| Rate for Payer: Humana KY Medicaid |
$1,240.10
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,252.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,956.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,661.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,264.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,173.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,704.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,884.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,137.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,488.14
|
| Rate for Payer: PHCS Commercial |
$3,461.76
|
| Rate for Payer: United Healthcare All Payer |
$3,173.28
|
|
|
CT ANGIO ABDOMINAL ARTERIES
|
Professional
|
Both
|
$3,606.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
35000013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$153.39 |
| Max. Negotiated Rate |
$2,163.60 |
| Rate for Payer: Aetna Commercial |
$724.71
|
| Rate for Payer: Ambetter Exchange |
$376.22
|
| Rate for Payer: Anthem Medicaid |
$300.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$376.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$376.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$451.46
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cash Price |
$1,803.00
|
| Rate for Payer: Cigna Commercial |
$1,013.89
|
| Rate for Payer: Healthspan PPO |
$679.07
|
| Rate for Payer: Humana Medicaid |
$300.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$153.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$376.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.88
|
| Rate for Payer: Molina Healthcare Passport |
$300.86
|
| Rate for Payer: Multiplan PHCS |
$2,163.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$489.09
|
| Rate for Payer: UHCCP Medicaid |
$1,262.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$376.22
|
|
|
CT ANGIO ABDOMINAL ARTERIES(P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
350P0013
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$96.25 |
| Max. Negotiated Rate |
$1,013.89 |
| Rate for Payer: Aetna Commercial |
$724.71
|
| Rate for Payer: Ambetter Exchange |
$376.22
|
| Rate for Payer: Anthem Medicaid |
$300.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$376.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$376.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$451.46
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$1,013.89
|
| Rate for Payer: Healthspan PPO |
$679.07
|
| Rate for Payer: Humana Medicaid |
$300.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$153.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$376.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.88
|
| Rate for Payer: Molina Healthcare Passport |
$300.86
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$489.09
|
| Rate for Payer: UHCCP Medicaid |
$96.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$376.22
|
|
|
CT ANGIO ABDOMINAL ARTERIES(T
|
Facility
|
IP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
350T0013
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABDOMINAL ARTERIES(T
|
Facility
|
OP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
350T0013
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABDOM W/O & W/DYE
|
Professional
|
Both
|
$3,556.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
35000007
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$121.70 |
| Max. Negotiated Rate |
$2,133.60 |
| Rate for Payer: Aetna Commercial |
$681.93
|
| Rate for Payer: Ambetter Exchange |
$280.10
|
| Rate for Payer: Anthem Medicaid |
$273.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$280.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$280.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$336.12
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cash Price |
$1,778.00
|
| Rate for Payer: Cigna Commercial |
$810.80
|
| Rate for Payer: Healthspan PPO |
$468.59
|
| Rate for Payer: Humana Medicaid |
$273.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$280.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.25
|
| Rate for Payer: Molina Healthcare Passport |
$273.77
|
| Rate for Payer: Multiplan PHCS |
$2,133.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$364.13
|
| Rate for Payer: UHCCP Medicaid |
$1,244.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$280.10
|
|
|
CT ANGIO ABDOM W/O & W/DYE
|
Facility
|
IP
|
$3,556.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
35000007
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABDOM W/O & W/DYE
|
Facility
|
OP
|
$3,556.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
35000007
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABDOM W/O & W/DYE(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
350P0007
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$810.80 |
| Rate for Payer: Aetna Commercial |
$681.93
|
| Rate for Payer: Ambetter Exchange |
$280.10
|
| Rate for Payer: Anthem Medicaid |
$273.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$280.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$280.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$336.12
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$810.80
|
| Rate for Payer: Healthspan PPO |
$468.59
|
| Rate for Payer: Humana Medicaid |
$273.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$280.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.25
|
| Rate for Payer: Molina Healthcare Passport |
$273.77
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$364.13
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$280.10
|
|
|
CT ANGIO ABDOM W/O & W/DYE(T
|
Facility
|
IP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
350T0007
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABDOM W/O & W/DYE(T
|
Facility
|
OP
|
$3,331.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
350T0007
|
|
Hospital Revenue Code
|
350
|
| 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
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE
|
Facility
|
OP
|
$6,890.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
35000006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$6,614.40 |
| Rate for Payer: Aetna Commercial |
$5,305.30
|
| Rate for Payer: Anthem Medicaid |
$2,369.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,374.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$3,445.00
|
| Rate for Payer: Cash Price |
$3,445.00
|
| Rate for Payer: Cigna Commercial |
$5,718.70
|
| Rate for Payer: First Health Commercial |
$6,545.50
|
| Rate for Payer: Humana Commercial |
$5,856.50
|
| Rate for Payer: Humana KY Medicaid |
$2,369.47
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,393.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,649.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,084.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,417.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,063.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,167.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,994.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,754.10
|
| Rate for Payer: PHCS Commercial |
$6,614.40
|
| Rate for Payer: United Healthcare All Payer |
$6,063.20
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE
|
Facility
|
IP
|
$6,890.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
35000006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,067.00 |
| Max. Negotiated Rate |
$6,614.40 |
| Rate for Payer: Aetna Commercial |
$5,305.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,374.20
|
| Rate for Payer: Cash Price |
$3,445.00
|
| Rate for Payer: Cigna Commercial |
$5,718.70
|
| Rate for Payer: First Health Commercial |
$6,545.50
|
| Rate for Payer: Humana Commercial |
$5,856.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,649.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,084.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,067.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,063.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,167.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,994.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,754.10
|
| Rate for Payer: PHCS Commercial |
$6,614.40
|
| Rate for Payer: United Healthcare All Payer |
$6,063.20
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE
|
Professional
|
Both
|
$6,890.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
35000006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$133.71 |
| Max. Negotiated Rate |
$4,134.00 |
| Rate for Payer: Ambetter Exchange |
$347.95
|
| Rate for Payer: Anthem Medicaid |
$434.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$347.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$417.54
|
| Rate for Payer: Cash Price |
$3,445.00
|
| Rate for Payer: Cash Price |
$3,445.00
|
| Rate for Payer: Cigna Commercial |
$920.51
|
| Rate for Payer: Healthspan PPO |
$420.86
|
| Rate for Payer: Humana Medicaid |
$434.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$133.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$347.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$443.51
|
| Rate for Payer: Molina Healthcare Passport |
$434.81
|
| Rate for Payer: Multiplan PHCS |
$4,134.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$452.33
|
| Rate for Payer: UHCCP Medicaid |
$2,411.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$439.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.95
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
350P0006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$920.51 |
| Rate for Payer: Ambetter Exchange |
$347.95
|
| Rate for Payer: Anthem Medicaid |
$434.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$347.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$417.54
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$920.51
|
| Rate for Payer: Healthspan PPO |
$420.86
|
| Rate for Payer: Humana Medicaid |
$434.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$133.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$347.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$443.51
|
| Rate for Payer: Molina Healthcare Passport |
$434.81
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$452.33
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$439.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.95
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE(T
|
Facility
|
OP
|
$6,665.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
350T0006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$329.98 |
| Max. Negotiated Rate |
$6,398.40 |
| Rate for Payer: Aetna Commercial |
$5,132.05
|
| Rate for Payer: Anthem Medicaid |
$2,292.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,198.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$3,332.50
|
| Rate for Payer: Cash Price |
$3,332.50
|
| Rate for Payer: Cigna Commercial |
$5,531.95
|
| Rate for Payer: First Health Commercial |
$6,331.75
|
| Rate for Payer: Humana Commercial |
$5,665.25
|
| Rate for Payer: Humana KY Medicaid |
$2,292.09
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,315.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,465.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,918.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,338.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,865.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,998.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,798.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,598.85
|
| Rate for Payer: PHCS Commercial |
$6,398.40
|
| Rate for Payer: United Healthcare All Payer |
$5,865.20
|
|
|
CT ANGIO ABD&PELV W/O&W/DYE(T
|
Facility
|
IP
|
$6,665.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
350T0006
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,999.50 |
| Max. Negotiated Rate |
$6,398.40 |
| Rate for Payer: Aetna Commercial |
$5,132.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,198.70
|
| Rate for Payer: Cash Price |
$3,332.50
|
| Rate for Payer: Cigna Commercial |
$5,531.95
|
| Rate for Payer: First Health Commercial |
$6,331.75
|
| Rate for Payer: Humana Commercial |
$5,665.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,465.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,918.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,999.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,865.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,998.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,332.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,798.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,598.85
|
| Rate for Payer: PHCS Commercial |
$6,398.40
|
| Rate for Payer: United Healthcare All Payer |
$5,865.20
|
|
|
CT ANGIOGRAPH PELV W/O&W/DYE
|
Professional
|
Both
|
$3,444.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
35000004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$116.14 |
| Max. Negotiated Rate |
$2,066.40 |
| Rate for Payer: Aetna Commercial |
$674.94
|
| Rate for Payer: Ambetter Exchange |
$278.89
|
| Rate for Payer: Anthem Medicaid |
$273.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$278.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$278.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$334.67
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: Cigna Commercial |
$792.87
|
| Rate for Payer: Healthspan PPO |
$463.78
|
| Rate for Payer: Humana Medicaid |
$273.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$278.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.25
|
| Rate for Payer: Molina Healthcare Passport |
$273.77
|
| Rate for Payer: Multiplan PHCS |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$362.56
|
| Rate for Payer: UHCCP Medicaid |
$1,205.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$278.89
|
|
|
CT ANGIOGRAPH PELV W/O&W/DYE
|
Facility
|
IP
|
$3,444.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
35000004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,033.20 |
| Max. Negotiated Rate |
$3,306.24 |
| Rate for Payer: Aetna Commercial |
$2,651.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.32
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: Cigna Commercial |
$2,858.52
|
| Rate for Payer: First Health Commercial |
$3,271.80
|
| Rate for Payer: Humana Commercial |
$2,927.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.36
|
| Rate for Payer: PHCS Commercial |
$3,306.24
|
| Rate for Payer: United Healthcare All Payer |
$3,030.72
|
|
|
CT ANGIOGRAPH PELV W/O&W/DYE
|
Facility
|
OP
|
$3,444.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
35000004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$3,306.24 |
| Rate for Payer: Aetna Commercial |
$2,651.88
|
| Rate for Payer: Anthem Medicaid |
$1,184.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: Cigna Commercial |
$2,858.52
|
| Rate for Payer: First Health Commercial |
$3,271.80
|
| Rate for Payer: Humana Commercial |
$2,927.40
|
| Rate for Payer: Humana KY Medicaid |
$1,184.39
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.36
|
| Rate for Payer: PHCS Commercial |
$3,306.24
|
| Rate for Payer: United Healthcare All Payer |
$3,030.72
|
|
|
CT ANGIOGRAPH PELV W/O&W/DY(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
350P0004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$792.87 |
| Rate for Payer: Aetna Commercial |
$674.94
|
| Rate for Payer: Ambetter Exchange |
$278.89
|
| Rate for Payer: Anthem Medicaid |
$273.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$278.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$278.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$334.67
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$792.87
|
| Rate for Payer: Healthspan PPO |
$463.78
|
| Rate for Payer: Humana Medicaid |
$273.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$278.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.25
|
| Rate for Payer: Molina Healthcare Passport |
$273.77
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$362.56
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$278.89
|
|
|
CT ANGIOGRAPH PELV W/O&W/DY(T
|
Facility
|
IP
|
$3,219.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
350T0004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$965.70 |
| Max. Negotiated Rate |
$3,090.24 |
| Rate for Payer: Aetna Commercial |
$2,478.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,510.82
|
| Rate for Payer: Cash Price |
$1,609.50
|
| Rate for Payer: Cigna Commercial |
$2,671.77
|
| Rate for Payer: First Health Commercial |
$3,058.05
|
| Rate for Payer: Humana Commercial |
$2,736.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,639.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,375.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$965.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,832.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,414.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,800.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,221.11
|
| Rate for Payer: PHCS Commercial |
$3,090.24
|
| Rate for Payer: United Healthcare All Payer |
$2,832.72
|
|
|
CT ANGIOGRAPH PELV W/O&W/DY(T
|
Facility
|
OP
|
$3,219.00
|
|
|
Service Code
|
HCPCS 72191
|
| Hospital Charge Code |
350T0004
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$3,090.24 |
| Rate for Payer: Aetna Commercial |
$2,478.63
|
| Rate for Payer: Anthem Medicaid |
$1,107.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,510.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,609.50
|
| Rate for Payer: Cash Price |
$1,609.50
|
| Rate for Payer: Cigna Commercial |
$2,671.77
|
| Rate for Payer: First Health Commercial |
$3,058.05
|
| Rate for Payer: Humana Commercial |
$2,736.15
|
| Rate for Payer: Humana KY Medicaid |
$1,107.01
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,118.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,639.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,375.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,129.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,832.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,414.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,800.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,221.11
|
| Rate for Payer: PHCS Commercial |
$3,090.24
|
| Rate for Payer: United Healthcare All Payer |
$2,832.72
|
|
