|
CT SCREENING CALC SCORE SP
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 75571
|
| Hospital Charge Code |
35000089
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
CT SCREENING CALC SCORE SP
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 75571
|
| Hospital Charge Code |
35000089
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$113.90 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
CT SCREENING CALC SCORE SP (T
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 75571
|
| Hospital Charge Code |
350T0089
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
CT SCREENING CALC SCORE SP (T
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 75571
|
| Hospital Charge Code |
350T0089
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$113.90 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
CT THORACIC SPINE W CONTRAST
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
35000044
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,723.52 |
| Rate for Payer: Aetna Commercial |
$2,184.49
|
| Rate for Payer: Anthem Medicaid |
$975.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,212.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,418.50
|
| Rate for Payer: Cash Price |
$1,418.50
|
| Rate for Payer: Cigna Commercial |
$2,354.71
|
| Rate for Payer: First Health Commercial |
$2,695.15
|
| Rate for Payer: Humana Commercial |
$2,411.45
|
| Rate for Payer: Humana KY Medicaid |
$975.64
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$985.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,326.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,093.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$995.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,496.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,127.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,269.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,468.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,957.53
|
| Rate for Payer: PHCS Commercial |
$2,723.52
|
| Rate for Payer: United Healthcare All Payer |
$2,496.56
|
|
|
CT THORACIC SPINE W CONTRAST
|
Professional
|
Both
|
$2,837.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
35000044
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$1,702.20 |
| Rate for Payer: Aetna Commercial |
$519.39
|
| Rate for Payer: Ambetter Exchange |
$156.47
|
| Rate for Payer: Anthem Medicaid |
$243.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$156.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$156.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.76
|
| Rate for Payer: Cash Price |
$1,418.50
|
| Rate for Payer: Cash Price |
$1,418.50
|
| Rate for Payer: Cigna Commercial |
$501.76
|
| Rate for Payer: Healthspan PPO |
$356.89
|
| Rate for Payer: Humana Medicaid |
$243.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$156.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$248.05
|
| Rate for Payer: Molina Healthcare Passport |
$243.19
|
| Rate for Payer: Multiplan PHCS |
$1,702.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.41
|
| Rate for Payer: UHCCP Medicaid |
$992.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$245.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$156.47
|
|
|
CT THORACIC SPINE W CONTRAST
|
Facility
|
IP
|
$2,837.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
35000044
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$851.10 |
| Max. Negotiated Rate |
$2,723.52 |
| Rate for Payer: Aetna Commercial |
$2,184.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,212.86
|
| Rate for Payer: Cash Price |
$1,418.50
|
| Rate for Payer: Cigna Commercial |
$2,354.71
|
| Rate for Payer: First Health Commercial |
$2,695.15
|
| Rate for Payer: Humana Commercial |
$2,411.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,326.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,093.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$851.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,496.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,127.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,269.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,468.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,957.53
|
| Rate for Payer: PHCS Commercial |
$2,723.52
|
| Rate for Payer: United Healthcare All Payer |
$2,496.56
|
|
|
CT THORACIC SPINE W CONTRAST(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
350P0044
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.88 |
| Max. Negotiated Rate |
$519.39 |
| Rate for Payer: Aetna Commercial |
$519.39
|
| Rate for Payer: Ambetter Exchange |
$156.47
|
| Rate for Payer: Anthem Medicaid |
$243.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$156.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$156.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.76
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$501.76
|
| Rate for Payer: Healthspan PPO |
$356.89
|
| Rate for Payer: Humana Medicaid |
$243.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$156.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$248.05
|
| Rate for Payer: Molina Healthcare Passport |
$243.19
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.41
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$245.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$156.47
|
|
|
CT THORACIC SPINE W CONTRAST(T
|
Facility
|
IP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
350T0044
|
|
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 THORACIC SPINE W CONTRAST(T
|
Facility
|
OP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
350T0044
|
|
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 THORACIC SPINE W/O CONTRAST
|
Facility
|
OP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
350T0043
|
|
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 THORACIC SPINE W/O CONTRAST
|
Facility
|
IP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
35000043
|
|
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 THORACIC SPINE W/O CONTRAST
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
35000043
|
|
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 THORACIC SPINE W/O CONTRAST
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
350P0043
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$64.78 |
| Max. Negotiated Rate |
$425.87 |
| Rate for Payer: Aetna Commercial |
$386.77
|
| Rate for Payer: Ambetter Exchange |
$119.47
|
| Rate for Payer: Anthem Medicaid |
$209.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$119.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$119.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$143.36
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$425.87
|
| Rate for Payer: Healthspan PPO |
$265.77
|
| Rate for Payer: Humana Medicaid |
$209.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$119.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.61
|
| Rate for Payer: Molina Healthcare Passport |
$209.42
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$155.31
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$119.47
|
|
|
CT THORACIC SPINE W/O CONTRAST
|
Facility
|
IP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
350T0043
|
|
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 THORACIC SPINE W/O CONTRAST
|
Professional
|
Both
|
$2,612.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
35000043
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$64.78 |
| Max. Negotiated Rate |
$1,567.20 |
| Rate for Payer: Aetna Commercial |
$386.77
|
| Rate for Payer: Ambetter Exchange |
$119.47
|
| Rate for Payer: Anthem Medicaid |
$209.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$119.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$119.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$143.36
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cigna Commercial |
$425.87
|
| Rate for Payer: Healthspan PPO |
$265.77
|
| Rate for Payer: Humana Medicaid |
$209.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$119.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.61
|
| Rate for Payer: Molina Healthcare Passport |
$209.42
|
| Rate for Payer: Multiplan PHCS |
$1,567.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$155.31
|
| Rate for Payer: UHCCP Medicaid |
$914.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$119.47
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Facility
|
OP
|
$2,616.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
350T0045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,511.36 |
| Rate for Payer: Aetna Commercial |
$2,014.32
|
| Rate for Payer: Anthem Medicaid |
$899.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,040.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,308.00
|
| Rate for Payer: Cash Price |
$1,308.00
|
| Rate for Payer: Cigna Commercial |
$2,171.28
|
| Rate for Payer: First Health Commercial |
$2,485.20
|
| Rate for Payer: Humana Commercial |
$2,223.60
|
| Rate for Payer: Humana KY Medicaid |
$899.64
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$908.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,145.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,930.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$917.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,302.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,962.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,092.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,275.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,805.04
|
| Rate for Payer: PHCS Commercial |
$2,511.36
|
| Rate for Payer: United Healthcare All Payer |
$2,302.08
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Facility
|
IP
|
$2,616.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
350T0045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$784.80 |
| Max. Negotiated Rate |
$2,511.36 |
| Rate for Payer: Aetna Commercial |
$2,014.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,040.48
|
| Rate for Payer: Cash Price |
$1,308.00
|
| Rate for Payer: Cigna Commercial |
$2,171.28
|
| Rate for Payer: First Health Commercial |
$2,485.20
|
| Rate for Payer: Humana Commercial |
$2,223.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,145.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,930.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$784.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,302.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,962.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,092.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,275.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,805.04
|
| Rate for Payer: PHCS Commercial |
$2,511.36
|
| Rate for Payer: United Healthcare All Payer |
$2,302.08
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Facility
|
IP
|
$2,866.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
35000045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$859.80 |
| Max. Negotiated Rate |
$2,751.36 |
| Rate for Payer: Aetna Commercial |
$2,206.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,235.48
|
| Rate for Payer: Cash Price |
$1,433.00
|
| Rate for Payer: Cigna Commercial |
$2,378.78
|
| Rate for Payer: First Health Commercial |
$2,722.70
|
| Rate for Payer: Humana Commercial |
$2,436.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,350.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,115.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$859.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,522.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,149.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,493.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,977.54
|
| Rate for Payer: PHCS Commercial |
$2,751.36
|
| Rate for Payer: United Healthcare All Payer |
$2,522.08
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
350P0045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$80.46 |
| Max. Negotiated Rate |
$616.99 |
| Rate for Payer: Aetna Commercial |
$616.99
|
| Rate for Payer: Ambetter Exchange |
$182.25
|
| Rate for Payer: Anthem Medicaid |
$293.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$182.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$182.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$218.70
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$609.07
|
| Rate for Payer: Healthspan PPO |
$423.96
|
| Rate for Payer: Humana Medicaid |
$293.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$182.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$299.08
|
| Rate for Payer: Molina Healthcare Passport |
$293.22
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$236.93
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$296.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$182.25
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Professional
|
Both
|
$2,866.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
35000045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$80.46 |
| Max. Negotiated Rate |
$1,719.60 |
| Rate for Payer: Aetna Commercial |
$616.99
|
| Rate for Payer: Ambetter Exchange |
$182.25
|
| Rate for Payer: Anthem Medicaid |
$293.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$182.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$182.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$218.70
|
| Rate for Payer: Cash Price |
$1,433.00
|
| Rate for Payer: Cash Price |
$1,433.00
|
| Rate for Payer: Cigna Commercial |
$609.07
|
| Rate for Payer: Healthspan PPO |
$423.96
|
| Rate for Payer: Humana Medicaid |
$293.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$182.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$299.08
|
| Rate for Payer: Molina Healthcare Passport |
$293.22
|
| Rate for Payer: Multiplan PHCS |
$1,719.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$236.93
|
| Rate for Payer: UHCCP Medicaid |
$1,003.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$296.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$182.25
|
|
|
CT THORACIC SPINE WWO CONTRAST
|
Facility
|
OP
|
$2,866.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
35000045
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,751.36 |
| Rate for Payer: Aetna Commercial |
$2,206.82
|
| Rate for Payer: Anthem Medicaid |
$985.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,235.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,433.00
|
| Rate for Payer: Cash Price |
$1,433.00
|
| Rate for Payer: Cigna Commercial |
$2,378.78
|
| Rate for Payer: First Health Commercial |
$2,722.70
|
| Rate for Payer: Humana Commercial |
$2,436.10
|
| Rate for Payer: Humana KY Medicaid |
$985.62
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$995.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,350.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,115.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,005.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,522.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,149.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,493.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,977.54
|
| Rate for Payer: PHCS Commercial |
$2,751.36
|
| Rate for Payer: United Healthcare All Payer |
$2,522.08
|
|
|
CT THORAX LUNG CANCER SCR C-
|
Professional
|
Both
|
$649.00
|
|
|
Service Code
|
HCPCS 71271
|
| Hospital Charge Code |
35000020
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$116.09 |
| Max. Negotiated Rate |
$389.40 |
| Rate for Payer: Ambetter Exchange |
$126.85
|
| Rate for Payer: Anthem Medicaid |
$116.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$152.22
|
| Rate for Payer: Cash Price |
$324.50
|
| Rate for Payer: Cash Price |
$324.50
|
| Rate for Payer: Humana Medicaid |
$116.09
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$118.41
|
| Rate for Payer: Molina Healthcare Passport |
$116.09
|
| Rate for Payer: Multiplan PHCS |
$389.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.91
|
| Rate for Payer: UHCCP Medicaid |
$227.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$117.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.85
|
|
|
CT THORAX LUNG CANCER SCR C-
|
Facility
|
OP
|
$649.00
|
|
|
Service Code
|
HCPCS 71271
|
| Hospital Charge Code |
35000020
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$623.04 |
| Rate for Payer: Aetna Commercial |
$499.73
|
| Rate for Payer: Anthem Medicaid |
$223.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$506.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$324.50
|
| Rate for Payer: Cash Price |
$324.50
|
| Rate for Payer: Cigna Commercial |
$538.67
|
| Rate for Payer: First Health Commercial |
$616.55
|
| Rate for Payer: Humana Commercial |
$551.65
|
| Rate for Payer: Humana KY Medicaid |
$223.19
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$225.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$532.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$478.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$227.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$571.12
|
| Rate for Payer: Ohio Health Group HMO |
$486.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$519.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$564.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.81
|
| Rate for Payer: PHCS Commercial |
$623.04
|
| Rate for Payer: United Healthcare All Payer |
$571.12
|
|
|
CT THORAX LUNG CANCER SCR C-
|
Facility
|
OP
|
$574.00
|
|
|
Service Code
|
HCPCS 71271
|
| Hospital Charge Code |
350T0020
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$551.04 |
| Rate for Payer: Aetna Commercial |
$441.98
|
| Rate for Payer: Anthem Medicaid |
$197.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$447.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cigna Commercial |
$476.42
|
| Rate for Payer: First Health Commercial |
$545.30
|
| Rate for Payer: Humana Commercial |
$487.90
|
| Rate for Payer: Humana KY Medicaid |
$197.40
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$199.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$470.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$423.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$201.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$505.12
|
| Rate for Payer: Ohio Health Group HMO |
$430.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.06
|
| Rate for Payer: PHCS Commercial |
$551.04
|
| Rate for Payer: United Healthcare All Payer |
$505.12
|
|
