|
CT THORAX LUNG CANCER SCR C-
|
Facility
|
IP
|
$574.00
|
|
|
Service Code
|
HCPCS 71271
|
| Hospital Charge Code |
350T0020
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$172.20 |
| Max. Negotiated Rate |
$551.04 |
| Rate for Payer: Aetna Commercial |
$441.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$447.72
|
| 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: 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 |
$172.20
|
| 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
|
|
|
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-
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 71271
|
| Hospital Charge Code |
350P0020
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$164.91 |
| 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 |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| 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 |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.91
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$117.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.85
|
|
|
CT UPPER EXTREMITY W/DYE
|
Facility
|
OP
|
$2,812.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
35000053
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$329.98 |
| 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 |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,193.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| 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 |
$329.98
|
| 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 |
$395.98
|
| 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 UPPER EXTREMITY W/DYE
|
Professional
|
Both
|
$2,812.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
35000053
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$74.02 |
| Max. Negotiated Rate |
$1,687.20 |
| Rate for Payer: Aetna Commercial |
$491.85
|
| Rate for Payer: Ambetter Exchange |
$182.78
|
| Rate for Payer: Anthem Medicaid |
$209.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$182.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$182.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$219.34
|
| Rate for Payer: Cash Price |
$1,406.00
|
| Rate for Payer: Cash Price |
$1,406.00
|
| Rate for Payer: Cigna Commercial |
$444.63
|
| Rate for Payer: Healthspan PPO |
$337.98
|
| Rate for Payer: Humana Medicaid |
$209.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$74.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$182.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.61
|
| Rate for Payer: Molina Healthcare Passport |
$209.42
|
| Rate for Payer: Multiplan PHCS |
$1,687.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$237.61
|
| Rate for Payer: UHCCP Medicaid |
$984.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$182.78
|
|
|
CT UPPER EXTREMITY W/DYE
|
Facility
|
IP
|
$2,812.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
35000053
|
|
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 UPPER EXTREMITY W/DYE(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
350P0053
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$74.02 |
| Max. Negotiated Rate |
$491.85 |
| Rate for Payer: Aetna Commercial |
$491.85
|
| Rate for Payer: Ambetter Exchange |
$182.78
|
| Rate for Payer: Anthem Medicaid |
$209.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$182.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$182.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$219.34
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$444.63
|
| Rate for Payer: Healthspan PPO |
$337.98
|
| Rate for Payer: Humana Medicaid |
$209.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$74.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$182.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.78
|
| 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 |
$237.61
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$182.78
|
|
|
CT UPPER EXTREMITY W/DYE(T
|
Facility
|
IP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
350T0053
|
|
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 UPPER EXTREMITY W/DYE(T
|
Facility
|
OP
|
$2,587.00
|
|
|
Service Code
|
HCPCS 73201
|
| Hospital Charge Code |
350T0053
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$329.98 |
| 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 |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,017.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| 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 |
$329.98
|
| 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 |
$395.98
|
| 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 UPPER EXTREMITY W/O DYE
|
Professional
|
Both
|
$2,612.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$65.01 |
| Max. Negotiated Rate |
$1,567.20 |
| Rate for Payer: Aetna Commercial |
$380.43
|
| Rate for Payer: Ambetter Exchange |
$147.21
|
| Rate for Payer: Anthem Medicaid |
$180.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.65
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cash Price |
$1,306.00
|
| Rate for Payer: Cigna Commercial |
$378.15
|
| Rate for Payer: Healthspan PPO |
$261.42
|
| Rate for Payer: Humana Medicaid |
$180.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$184.33
|
| Rate for Payer: Molina Healthcare Passport |
$180.72
|
| Rate for Payer: Multiplan PHCS |
$1,567.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.37
|
| Rate for Payer: UHCCP Medicaid |
$914.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$182.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.21
|
|
|
CT UPPER EXTREMITY W/O DYE
|
Facility
|
IP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
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 UPPER EXTREMITY W/O DYE
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
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 UPPER EXTREMITY W/O DYE(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350P0052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$65.01 |
| Max. Negotiated Rate |
$380.43 |
| Rate for Payer: Aetna Commercial |
$380.43
|
| Rate for Payer: Ambetter Exchange |
$147.21
|
| Rate for Payer: Anthem Medicaid |
$180.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.65
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$378.15
|
| Rate for Payer: Healthspan PPO |
$261.42
|
| Rate for Payer: Humana Medicaid |
$180.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$184.33
|
| Rate for Payer: Molina Healthcare Passport |
$180.72
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.37
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$182.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.21
|
|
|
CT UPPER EXTREMITY W/O DYE(T
|
Facility
|
OP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350T0052
|
|
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 UPPER EXTREMITY W/O DYE(T
|
Facility
|
IP
|
$2,387.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350T0052
|
|
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 UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$2,942.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,824.32 |
| Rate for Payer: Aetna Commercial |
$2,265.34
|
| Rate for Payer: Anthem Medicaid |
$1,011.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,294.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cigna Commercial |
$2,441.86
|
| Rate for Payer: First Health Commercial |
$2,794.90
|
| Rate for Payer: Humana Commercial |
$2,500.70
|
| Rate for Payer: Humana KY Medicaid |
$1,011.75
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,022.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,412.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,032.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,588.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,559.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.98
|
| Rate for Payer: PHCS Commercial |
$2,824.32
|
| Rate for Payer: United Healthcare All Payer |
$2,588.96
|
|
|
CT UPPR EXTREMITY W/O&W/DYE
|
Professional
|
Both
|
$2,942.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$1,765.20 |
| Rate for Payer: Aetna Commercial |
$611.08
|
| Rate for Payer: Ambetter Exchange |
$224.54
|
| Rate for Payer: Anthem Medicaid |
$252.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$224.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$224.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$269.45
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cigna Commercial |
$551.98
|
| Rate for Payer: Healthspan PPO |
$419.90
|
| Rate for Payer: Humana Medicaid |
$252.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$224.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$224.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.85
|
| Rate for Payer: Molina Healthcare Passport |
$252.79
|
| Rate for Payer: Multiplan PHCS |
$1,765.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$291.90
|
| Rate for Payer: UHCCP Medicaid |
$1,029.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$224.54
|
|
|
CT UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$2,942.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$882.60 |
| Max. Negotiated Rate |
$2,824.32 |
| Rate for Payer: Aetna Commercial |
$2,265.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,294.76
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cigna Commercial |
$2,441.86
|
| Rate for Payer: First Health Commercial |
$2,794.90
|
| Rate for Payer: Humana Commercial |
$2,500.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,412.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,588.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,559.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.98
|
| Rate for Payer: PHCS Commercial |
$2,824.32
|
| Rate for Payer: United Healthcare All Payer |
$2,588.96
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350P0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$611.08 |
| Rate for Payer: Aetna Commercial |
$611.08
|
| Rate for Payer: Ambetter Exchange |
$224.54
|
| Rate for Payer: Anthem Medicaid |
$252.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$224.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$224.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$269.45
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$551.98
|
| Rate for Payer: Healthspan PPO |
$419.90
|
| Rate for Payer: Humana Medicaid |
$252.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$224.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$224.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.85
|
| Rate for Payer: Molina Healthcare Passport |
$252.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$291.90
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$224.54
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(T
|
Facility
|
IP
|
$2,692.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350T0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$807.60 |
| Max. Negotiated Rate |
$2,584.32 |
| Rate for Payer: Aetna Commercial |
$2,072.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,099.76
|
| Rate for Payer: Cash Price |
$1,346.00
|
| Rate for Payer: Cigna Commercial |
$2,234.36
|
| Rate for Payer: First Health Commercial |
$2,557.40
|
| Rate for Payer: Humana Commercial |
$2,288.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,207.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,986.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$807.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,368.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,019.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,342.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,857.48
|
| Rate for Payer: PHCS Commercial |
$2,584.32
|
| Rate for Payer: United Healthcare All Payer |
$2,368.96
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(T
|
Facility
|
OP
|
$2,692.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350T0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$2,584.32 |
| Rate for Payer: Aetna Commercial |
$2,072.84
|
| Rate for Payer: Anthem Medicaid |
$925.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,099.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$1,346.00
|
| Rate for Payer: Cash Price |
$1,346.00
|
| Rate for Payer: Cigna Commercial |
$2,234.36
|
| Rate for Payer: First Health Commercial |
$2,557.40
|
| Rate for Payer: Humana Commercial |
$2,288.20
|
| Rate for Payer: Humana KY Medicaid |
$925.78
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$935.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,207.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,986.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$944.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,368.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,019.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,342.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,857.48
|
| Rate for Payer: PHCS Commercial |
$2,584.32
|
| Rate for Payer: United Healthcare All Payer |
$2,368.96
|
|
|
[C]TUSSIONEX (COMB) SUSPEN 5ML
|
Facility
|
OP
|
$62.41
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
25000124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$59.91 |
| Rate for Payer: Aetna Commercial |
$48.06
|
| Rate for Payer: Anthem Medicaid |
$21.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.68
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$51.80
|
| Rate for Payer: First Health Commercial |
$59.29
|
| Rate for Payer: Humana Commercial |
$53.05
|
| Rate for Payer: Humana KY Medicaid |
$21.46
|
| Rate for Payer: Kentucky WC Medicaid |
$21.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.92
|
| Rate for Payer: Ohio Health Group HMO |
$46.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.06
|
| Rate for Payer: PHCS Commercial |
$59.91
|
| Rate for Payer: United Healthcare All Payer |
$54.92
|
|
|
[C]TUSSIONEX (COMB) SUSPEN 5ML
|
Facility
|
IP
|
$62.41
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
25000124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$59.91 |
| Rate for Payer: Aetna Commercial |
$48.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.68
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$51.80
|
| Rate for Payer: First Health Commercial |
$59.29
|
| Rate for Payer: Humana Commercial |
$53.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.92
|
| Rate for Payer: Ohio Health Group HMO |
$46.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.06
|
| Rate for Payer: PHCS Commercial |
$59.91
|
| Rate for Payer: United Healthcare All Payer |
$54.92
|
|
|
[C]TYLENOL #2 (ACETAMIN. 1TAB
|
Facility
|
OP
|
$60.42
|
|
|
Service Code
|
NDC 406048301
|
| Hospital Charge Code |
25000083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem Medicaid |
$20.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Humana KY Medicaid |
$20.78
|
| Rate for Payer: Kentucky WC Medicaid |
$20.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.69
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
[C]TYLENOL #2 (ACETAMIN. 1TAB
|
Facility
|
IP
|
$60.42
|
|
|
Service Code
|
NDC 406048301
|
| Hospital Charge Code |
25000083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.69
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
