|
CT PELVIS W/CONTRAST
|
Facility
|
IP
|
$2,812.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
35000050
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$843.60 |
| Max. Negotiated Rate |
$2,699.52 |
| Rate for Payer: Aetna Commercial |
$2,165.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,193.36
|
| Rate for Payer: Cash Price |
$1,406.00
|
| Rate for Payer: Cigna Commercial |
$2,333.96
|
| Rate for Payer: First Health Commercial |
$2,671.40
|
| Rate for Payer: Humana Commercial |
$2,390.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,305.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,075.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$843.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,474.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,109.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,249.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,446.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,940.28
|
| Rate for Payer: PHCS Commercial |
$2,699.52
|
| Rate for Payer: United Healthcare All Payer |
$2,474.56
|
|
|
CT PELVIS W/CONTRAST
|
Facility
|
OP
|
$2,812.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
35000050
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,699.52 |
| Rate for Payer: Aetna Commercial |
$2,165.24
|
| Rate for Payer: Anthem Medicaid |
$967.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,193.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,406.00
|
| Rate for Payer: Cash Price |
$1,406.00
|
| Rate for Payer: Cigna Commercial |
$2,333.96
|
| Rate for Payer: First Health Commercial |
$2,671.40
|
| Rate for Payer: Humana Commercial |
$2,390.20
|
| Rate for Payer: Humana KY Medicaid |
$967.05
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,305.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,075.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$986.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,474.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,109.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,249.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,446.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,940.28
|
| Rate for Payer: PHCS Commercial |
$2,699.52
|
| Rate for Payer: United Healthcare All Payer |
$2,474.56
|
|
|
CT PELVIS W/CONTRAST(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
350P0050
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$74.02 |
| Max. Negotiated Rate |
$493.80 |
| Rate for Payer: Aetna Commercial |
$493.80
|
| Rate for Payer: Ambetter Exchange |
$206.94
|
| Rate for Payer: Anthem Medicaid |
$234.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$206.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$206.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$248.33
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$481.66
|
| Rate for Payer: Healthspan PPO |
$339.32
|
| Rate for Payer: Humana Medicaid |
$234.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$74.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$206.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$239.19
|
| Rate for Payer: Molina Healthcare Passport |
$234.50
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.02
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$206.94
|
|
|
CT PELVIS W/CONTRAST(T
|
Facility
|
IP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
350T0050
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$776.10 |
| Max. Negotiated Rate |
$2,483.52 |
| Rate for Payer: Aetna Commercial |
$1,991.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,017.86
|
| Rate for Payer: Cash Price |
$1,293.50
|
| Rate for Payer: Cigna Commercial |
$2,147.21
|
| Rate for Payer: First Health Commercial |
$2,457.65
|
| Rate for Payer: Humana Commercial |
$2,198.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,121.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,909.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$776.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,276.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,940.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,069.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,250.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,785.03
|
| Rate for Payer: PHCS Commercial |
$2,483.52
|
| Rate for Payer: United Healthcare All Payer |
$2,276.56
|
|
|
CT PELVIS W/CONTRAST(T
|
Facility
|
OP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
350T0050
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,483.52 |
| Rate for Payer: Aetna Commercial |
$1,991.99
|
| Rate for Payer: Anthem Medicaid |
$889.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,017.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,293.50
|
| Rate for Payer: Cash Price |
$1,293.50
|
| Rate for Payer: Cigna Commercial |
$2,147.21
|
| Rate for Payer: First Health Commercial |
$2,457.65
|
| Rate for Payer: Humana Commercial |
$2,198.95
|
| Rate for Payer: Humana KY Medicaid |
$889.67
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$898.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,121.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,909.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$907.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,276.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,940.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,069.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,250.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,785.03
|
| Rate for Payer: PHCS Commercial |
$2,483.52
|
| Rate for Payer: United Healthcare All Payer |
$2,276.56
|
|
|
CT PELVIS W/O CONTRAST
|
Professional
|
Both
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
35000049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$68.68 |
| Max. Negotiated Rate |
$1,567.20 |
| Rate for Payer: Aetna Commercial |
$381.84
|
| Rate for Payer: Ambetter Exchange |
$122.72
|
| Rate for Payer: Anthem Medicaid |
$206.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.26
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cigna Commercial |
$415.73
|
| Rate for Payer: Healthspan PPO |
$262.38
|
| Rate for Payer: Humana Medicaid |
$206.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$210.44
|
| Rate for Payer: Molina Healthcare Passport |
$206.31
|
| Rate for Payer: Multiplan PHCS |
$1,567.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.54
|
| Rate for Payer: UHCCP Medicaid |
$914.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$208.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.72
|
|
|
CT PELVIS W/O CONTRAST
|
Facility
|
IP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
35000049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$783.60 |
| Max. Negotiated Rate |
$2,507.52 |
| Rate for Payer: Aetna Commercial |
$2,011.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,037.36
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cigna Commercial |
$2,167.96
|
| Rate for Payer: First Health Commercial |
$2,481.40
|
| Rate for Payer: Humana Commercial |
$2,220.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,141.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,927.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$783.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,298.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,959.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,272.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,802.28
|
| Rate for Payer: PHCS Commercial |
$2,507.52
|
| Rate for Payer: United Healthcare All Payer |
$2,298.56
|
|
|
CT PELVIS W/O CONTRAST
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
35000049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$2,507.52 |
| Rate for Payer: Aetna Commercial |
$2,011.24
|
| Rate for Payer: Anthem Medicaid |
$898.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,037.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cigna Commercial |
$2,167.96
|
| Rate for Payer: First Health Commercial |
$2,481.40
|
| Rate for Payer: Humana Commercial |
$2,220.20
|
| Rate for Payer: Humana KY Medicaid |
$898.27
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$907.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,141.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,927.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$916.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,298.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,959.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,272.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,802.28
|
| Rate for Payer: PHCS Commercial |
$2,507.52
|
| Rate for Payer: United Healthcare All Payer |
$2,298.56
|
|
|
CT PELVIS W/O CONTRAST(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
350P0049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$68.68 |
| Max. Negotiated Rate |
$415.73 |
| Rate for Payer: Aetna Commercial |
$381.84
|
| Rate for Payer: Ambetter Exchange |
$122.72
|
| Rate for Payer: Anthem Medicaid |
$206.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.26
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$415.73
|
| Rate for Payer: Healthspan PPO |
$262.38
|
| Rate for Payer: Humana Medicaid |
$206.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$210.44
|
| Rate for Payer: Molina Healthcare Passport |
$206.31
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.54
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$208.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.72
|
|
|
CT PELVIS W/O CONTRAST(T
|
Facility
|
OP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
350T0049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$2,291.52 |
| Rate for Payer: Aetna Commercial |
$1,837.99
|
| Rate for Payer: Anthem Medicaid |
$820.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,861.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$1,193.50
|
| Rate for Payer: Cash Price |
$1,193.50
|
| Rate for Payer: Cigna Commercial |
$1,981.21
|
| Rate for Payer: First Health Commercial |
$2,267.65
|
| Rate for Payer: Humana Commercial |
$2,028.95
|
| Rate for Payer: Humana KY Medicaid |
$820.89
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$829.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,957.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,761.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$837.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,100.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,790.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,909.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,076.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,647.03
|
| Rate for Payer: PHCS Commercial |
$2,291.52
|
| Rate for Payer: United Healthcare All Payer |
$2,100.56
|
|
|
CT PELVIS W/O CONTRAST(T
|
Facility
|
IP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
350T0049
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$716.10 |
| Max. Negotiated Rate |
$2,291.52 |
| Rate for Payer: Aetna Commercial |
$1,837.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,861.86
|
| Rate for Payer: Cash Price |
$1,193.50
|
| Rate for Payer: Cigna Commercial |
$1,981.21
|
| Rate for Payer: First Health Commercial |
$2,267.65
|
| Rate for Payer: Humana Commercial |
$2,028.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,957.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,761.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$716.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,100.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,790.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,909.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,076.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,647.03
|
| Rate for Payer: PHCS Commercial |
$2,291.52
|
| Rate for Payer: United Healthcare All Payer |
$2,100.56
|
|
|
CT PELVIS W & WO CONTRAST
|
Facility
|
OP
|
$3,012.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
35000051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,891.52 |
| Rate for Payer: Aetna Commercial |
$2,319.24
|
| Rate for Payer: Anthem Medicaid |
$1,035.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,349.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,506.00
|
| Rate for Payer: Cash Price |
$1,506.00
|
| Rate for Payer: Cigna Commercial |
$2,499.96
|
| Rate for Payer: First Health Commercial |
$2,861.40
|
| Rate for Payer: Humana Commercial |
$2,560.20
|
| Rate for Payer: Humana KY Medicaid |
$1,035.83
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,046.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,469.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,222.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,056.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,650.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,259.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,409.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,620.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,078.28
|
| Rate for Payer: PHCS Commercial |
$2,891.52
|
| Rate for Payer: United Healthcare All Payer |
$2,650.56
|
|
|
CT PELVIS W & WO CONTRAST
|
Professional
|
Both
|
$3,012.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
35000051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$1,807.20 |
| Rate for Payer: Aetna Commercial |
$611.78
|
| Rate for Payer: Ambetter Exchange |
$228.33
|
| Rate for Payer: Anthem Medicaid |
$281.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$228.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$228.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$274.00
|
| Rate for Payer: Cash Price |
$1,506.00
|
| Rate for Payer: Cash Price |
$1,506.00
|
| Rate for Payer: Cigna Commercial |
$591.74
|
| Rate for Payer: Healthspan PPO |
$420.39
|
| Rate for Payer: Humana Medicaid |
$281.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$228.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$286.72
|
| Rate for Payer: Molina Healthcare Passport |
$281.10
|
| Rate for Payer: Multiplan PHCS |
$1,807.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$296.83
|
| Rate for Payer: UHCCP Medicaid |
$1,054.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$283.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$228.33
|
|
|
CT PELVIS W & WO CONTRAST
|
Facility
|
IP
|
$3,012.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
35000051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$903.60 |
| Max. Negotiated Rate |
$2,891.52 |
| Rate for Payer: Aetna Commercial |
$2,319.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,349.36
|
| Rate for Payer: Cash Price |
$1,506.00
|
| Rate for Payer: Cigna Commercial |
$2,499.96
|
| Rate for Payer: First Health Commercial |
$2,861.40
|
| Rate for Payer: Humana Commercial |
$2,560.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,469.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,222.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$903.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,650.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,259.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,409.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,620.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,078.28
|
| Rate for Payer: PHCS Commercial |
$2,891.52
|
| Rate for Payer: United Healthcare All Payer |
$2,650.56
|
|
|
CT PELVIS W & WO CONTRAST(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
350P0051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$611.78 |
| Rate for Payer: Aetna Commercial |
$611.78
|
| Rate for Payer: Ambetter Exchange |
$228.33
|
| Rate for Payer: Anthem Medicaid |
$281.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$228.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$228.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$274.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$591.74
|
| Rate for Payer: Healthspan PPO |
$420.39
|
| Rate for Payer: Humana Medicaid |
$281.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$228.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$286.72
|
| Rate for Payer: Molina Healthcare Passport |
$281.10
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$296.83
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$283.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$228.33
|
|
|
CT PELVIS W & WO CONTRAST(T
|
Facility
|
IP
|
$2,787.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
350T0051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$836.10 |
| Max. Negotiated Rate |
$2,675.52 |
| Rate for Payer: Aetna Commercial |
$2,145.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,173.86
|
| Rate for Payer: Cash Price |
$1,393.50
|
| Rate for Payer: Cigna Commercial |
$2,313.21
|
| Rate for Payer: First Health Commercial |
$2,647.65
|
| Rate for Payer: Humana Commercial |
$2,368.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,285.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,056.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$836.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,452.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,090.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,424.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,923.03
|
| Rate for Payer: PHCS Commercial |
$2,675.52
|
| Rate for Payer: United Healthcare All Payer |
$2,452.56
|
|
|
CT PELVIS W & WO CONTRAST(T
|
Facility
|
OP
|
$2,787.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
350T0051
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,675.52 |
| Rate for Payer: Aetna Commercial |
$2,145.99
|
| Rate for Payer: Anthem Medicaid |
$958.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,173.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,393.50
|
| Rate for Payer: Cash Price |
$1,393.50
|
| Rate for Payer: Cigna Commercial |
$2,313.21
|
| Rate for Payer: First Health Commercial |
$2,647.65
|
| Rate for Payer: Humana Commercial |
$2,368.95
|
| Rate for Payer: Humana KY Medicaid |
$958.45
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$968.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,285.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,056.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$977.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,452.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,090.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,424.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,923.03
|
| Rate for Payer: PHCS Commercial |
$2,675.52
|
| Rate for Payer: United Healthcare All Payer |
$2,452.56
|
|
|
[C]TRANXENE(CLORAZ 3.75MG/1TAB
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
NDC 13107031901
|
| Hospital Charge Code |
25000123
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$58.56 |
| Rate for Payer: Aetna Commercial |
$46.97
|
| Rate for Payer: Anthem Medicaid |
$20.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.58
|
| Rate for Payer: Cash Price |
$30.50
|
| Rate for Payer: Cigna Commercial |
$50.63
|
| Rate for Payer: First Health Commercial |
$57.95
|
| Rate for Payer: Humana Commercial |
$51.85
|
| Rate for Payer: Humana KY Medicaid |
$20.98
|
| Rate for Payer: Kentucky WC Medicaid |
$21.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.68
|
| Rate for Payer: Ohio Health Group HMO |
$45.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.09
|
| Rate for Payer: PHCS Commercial |
$58.56
|
| Rate for Payer: United Healthcare All Payer |
$53.68
|
|
|
[C]TRANXENE(CLORAZ 3.75MG/1TAB
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
NDC 13107031901
|
| Hospital Charge Code |
25000123
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$58.56 |
| Rate for Payer: Aetna Commercial |
$46.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.58
|
| Rate for Payer: Cash Price |
$30.50
|
| Rate for Payer: Cigna Commercial |
$50.63
|
| Rate for Payer: First Health Commercial |
$57.95
|
| Rate for Payer: Humana Commercial |
$51.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.68
|
| Rate for Payer: Ohio Health Group HMO |
$45.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.09
|
| Rate for Payer: PHCS Commercial |
$58.56
|
| Rate for Payer: United Healthcare All Payer |
$53.68
|
|
|
CT SCAN FOR THERAPY GUIDE
|
Facility
|
IP
|
$1,292.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
35000019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$1,240.32 |
| Rate for Payer: Aetna Commercial |
$994.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,007.76
|
| Rate for Payer: Cash Price |
$646.00
|
| Rate for Payer: Cigna Commercial |
$1,072.36
|
| Rate for Payer: First Health Commercial |
$1,227.40
|
| Rate for Payer: Humana Commercial |
$1,098.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,059.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$953.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,136.96
|
| Rate for Payer: Ohio Health Group HMO |
$969.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,033.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$891.48
|
| Rate for Payer: PHCS Commercial |
$1,240.32
|
| Rate for Payer: United Healthcare All Payer |
$1,136.96
|
|
|
CT SCAN FOR THERAPY GUIDE
|
Professional
|
Both
|
$1,292.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
35000019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$53.99 |
| Max. Negotiated Rate |
$775.20 |
| Rate for Payer: Aetna Commercial |
$281.66
|
| Rate for Payer: Ambetter Exchange |
$108.14
|
| Rate for Payer: Anthem Medicaid |
$119.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$108.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.77
|
| Rate for Payer: Cash Price |
$646.00
|
| Rate for Payer: Cash Price |
$646.00
|
| Rate for Payer: Cigna Commercial |
$250.86
|
| Rate for Payer: Healthspan PPO |
$263.93
|
| Rate for Payer: Humana Medicaid |
$119.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$108.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.49
|
| Rate for Payer: Molina Healthcare Passport |
$119.11
|
| Rate for Payer: Multiplan PHCS |
$775.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.58
|
| Rate for Payer: UHCCP Medicaid |
$452.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$108.14
|
|
|
CT SCAN FOR THERAPY GUIDE
|
Facility
|
OP
|
$1,292.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
35000019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$1,240.32 |
| Rate for Payer: Aetna Commercial |
$994.84
|
| Rate for Payer: Anthem Medicaid |
$444.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,007.76
|
| Rate for Payer: Cash Price |
$646.00
|
| Rate for Payer: Cigna Commercial |
$1,072.36
|
| Rate for Payer: First Health Commercial |
$1,227.40
|
| Rate for Payer: Humana Commercial |
$1,098.20
|
| Rate for Payer: Humana KY Medicaid |
$444.32
|
| Rate for Payer: Kentucky WC Medicaid |
$448.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,059.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$953.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,136.96
|
| Rate for Payer: Ohio Health Group HMO |
$969.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,033.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$891.48
|
| Rate for Payer: PHCS Commercial |
$1,240.32
|
| Rate for Payer: United Healthcare All Payer |
$1,136.96
|
|
|
CT SCAN FOR THERAPY GUIDE(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
350P0019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$281.66 |
| Rate for Payer: Aetna Commercial |
$281.66
|
| Rate for Payer: Ambetter Exchange |
$108.14
|
| Rate for Payer: Anthem Medicaid |
$119.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$108.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$108.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.77
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$250.86
|
| Rate for Payer: Healthspan PPO |
$263.93
|
| Rate for Payer: Humana Medicaid |
$119.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$108.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.49
|
| Rate for Payer: Molina Healthcare Passport |
$119.11
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.58
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$108.14
|
|
|
CT SCAN FOR THERAPY GUIDE(T
|
Facility
|
IP
|
$1,167.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
350T0019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$350.10 |
| Max. Negotiated Rate |
$1,120.32 |
| Rate for Payer: Aetna Commercial |
$898.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$910.26
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cigna Commercial |
$968.61
|
| Rate for Payer: First Health Commercial |
$1,108.65
|
| Rate for Payer: Humana Commercial |
$991.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.96
|
| Rate for Payer: Ohio Health Group HMO |
$875.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,015.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$805.23
|
| Rate for Payer: PHCS Commercial |
$1,120.32
|
| Rate for Payer: United Healthcare All Payer |
$1,026.96
|
|
|
CT SCAN FOR THERAPY GUIDE(T
|
Facility
|
OP
|
$1,167.00
|
|
|
Service Code
|
HCPCS 77014
|
| Hospital Charge Code |
350T0019
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$350.10 |
| Max. Negotiated Rate |
$1,120.32 |
| Rate for Payer: Aetna Commercial |
$898.59
|
| Rate for Payer: Anthem Medicaid |
$401.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$910.26
|
| Rate for Payer: Cash Price |
$583.50
|
| Rate for Payer: Cigna Commercial |
$968.61
|
| Rate for Payer: First Health Commercial |
$1,108.65
|
| Rate for Payer: Humana Commercial |
$991.95
|
| Rate for Payer: Humana KY Medicaid |
$401.33
|
| Rate for Payer: Kentucky WC Medicaid |
$405.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$956.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$409.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,026.96
|
| Rate for Payer: Ohio Health Group HMO |
$875.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$933.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,015.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$805.23
|
| Rate for Payer: PHCS Commercial |
$1,120.32
|
| Rate for Payer: United Healthcare All Payer |
$1,026.96
|
|
