|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Professional
|
Both
|
$541.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$541.00 |
| Rate for Payer: Aetna Commercial |
$249.25
|
| Rate for Payer: Anthem Medicaid |
$89.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$541.00
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cigna Commercial |
$205.36
|
| Rate for Payer: Healthspan PPO |
$266.25
|
| Rate for Payer: Humana Medicaid |
$89.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.84
|
| Rate for Payer: Molina Healthcare Passport |
$89.06
|
| Rate for Payer: Multiplan PHCS |
$324.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.70
|
| Rate for Payer: UHCCP Medicaid |
$189.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.95
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921P0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$266.25 |
| Rate for Payer: Aetna Commercial |
$249.25
|
| Rate for Payer: Anthem Medicaid |
$89.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$205.36
|
| Rate for Payer: Healthspan PPO |
$266.25
|
| Rate for Payer: Humana Medicaid |
$89.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.84
|
| Rate for Payer: Molina Healthcare Passport |
$89.06
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.95
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92000006
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Aetna Commercial |
$224.07
|
| Rate for Payer: Anthem Medicaid |
$100.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$241.53
|
| Rate for Payer: First Health Commercial |
$276.45
|
| Rate for Payer: Humana Commercial |
$247.35
|
| Rate for Payer: Humana KY Medicaid |
$100.07
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$101.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.08
|
| Rate for Payer: Ohio Health Group HMO |
$218.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.21
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
IP
|
$541.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$519.36 |
| Rate for Payer: Aetna Commercial |
$416.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.98
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cigna Commercial |
$449.03
|
| Rate for Payer: First Health Commercial |
$513.95
|
| Rate for Payer: Humana Commercial |
$459.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.08
|
| Rate for Payer: Ohio Health Group HMO |
$405.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.71
|
| Rate for Payer: PHCS Commercial |
$519.36
|
| Rate for Payer: United Healthcare All Payer |
$476.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$541.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
92100003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$519.36 |
| Rate for Payer: Aetna Commercial |
$416.57
|
| Rate for Payer: Anthem Medicaid |
$186.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cigna Commercial |
$449.03
|
| Rate for Payer: First Health Commercial |
$513.95
|
| Rate for Payer: Humana Commercial |
$459.85
|
| Rate for Payer: Humana KY Medicaid |
$186.05
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$187.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.08
|
| Rate for Payer: Ohio Health Group HMO |
$405.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.71
|
| Rate for Payer: PHCS Commercial |
$519.36
|
| Rate for Payer: United Healthcare All Payer |
$476.08
|
|
|
DUP SCAN OF EXTRACRANIAL LIMIT
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
HCPCS 93882
|
| Hospital Charge Code |
921T0003
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Aetna Commercial |
$224.07
|
| Rate for Payer: Anthem Medicaid |
$100.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$241.53
|
| Rate for Payer: First Health Commercial |
$276.45
|
| Rate for Payer: Humana Commercial |
$247.35
|
| Rate for Payer: Humana KY Medicaid |
$100.07
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$101.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$238.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.08
|
| Rate for Payer: Ohio Health Group HMO |
$218.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.21
|
| Rate for Payer: PHCS Commercial |
$279.36
|
| Rate for Payer: United Healthcare All Payer |
$256.08
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921T0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
OP
|
$560.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$537.60 |
| Rate for Payer: Aetna Commercial |
$431.20
|
| Rate for Payer: Anthem Medicaid |
$192.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$464.80
|
| Rate for Payer: First Health Commercial |
$532.00
|
| Rate for Payer: Humana Commercial |
$476.00
|
| Rate for Payer: Humana KY Medicaid |
$192.58
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$194.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$459.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$413.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.80
|
| Rate for Payer: Ohio Health Group HMO |
$420.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.60
|
| Rate for Payer: PHCS Commercial |
$537.60
|
| Rate for Payer: United Healthcare All Payer |
$492.80
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Aetna Commercial |
$270.01
|
| Rate for Payer: Anthem Medicaid |
$137.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$560.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$306.90
|
| Rate for Payer: Healthspan PPO |
$288.43
|
| Rate for Payer: Humana Medicaid |
$137.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.77
|
| Rate for Payer: Molina Healthcare Passport |
$137.03
|
| Rate for Payer: Multiplan PHCS |
$336.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$392.00
|
| Rate for Payer: UHCCP Medicaid |
$196.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.40
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921T0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem Medicaid |
$142.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Humana KY Medicaid |
$142.72
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$144.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
IP
|
$560.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$537.60 |
| Rate for Payer: Aetna Commercial |
$431.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.80
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$464.80
|
| Rate for Payer: First Health Commercial |
$532.00
|
| Rate for Payer: Humana Commercial |
$476.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$459.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$413.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.80
|
| Rate for Payer: Ohio Health Group HMO |
$420.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.60
|
| Rate for Payer: PHCS Commercial |
$537.60
|
| Rate for Payer: United Healthcare All Payer |
$492.80
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921P0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$306.90 |
| Rate for Payer: Aetna Commercial |
$270.01
|
| Rate for Payer: Anthem Medicaid |
$137.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$145.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$306.90
|
| Rate for Payer: Healthspan PPO |
$288.43
|
| Rate for Payer: Humana Medicaid |
$137.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.77
|
| Rate for Payer: Molina Healthcare Passport |
$137.03
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.50
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.40
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921P0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$202.24 |
| Rate for Payer: Aetna Commercial |
$173.24
|
| Rate for Payer: Anthem Medicaid |
$91.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$202.24
|
| Rate for Payer: Healthspan PPO |
$185.06
|
| Rate for Payer: Humana Medicaid |
$91.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.01
|
| Rate for Payer: Molina Healthcare Passport |
$91.19
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.10
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$173.24
|
| Rate for Payer: Anthem Medicaid |
$91.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$202.24
|
| Rate for Payer: Healthspan PPO |
$185.06
|
| Rate for Payer: Humana Medicaid |
$91.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.01
|
| Rate for Payer: Molina Healthcare Passport |
$91.19
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.10
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.92
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921T0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$531.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.20
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$572.70
|
| Rate for Payer: First Health Commercial |
$655.50
|
| Rate for Payer: Humana Commercial |
$586.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.20
|
| Rate for Payer: Ohio Health Group HMO |
$517.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$662.40
|
| Rate for Payer: United Healthcare All Payer |
$607.20
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921T0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$531.30
|
| Rate for Payer: Anthem Medicaid |
$237.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$572.70
|
| Rate for Payer: First Health Commercial |
$655.50
|
| Rate for Payer: Humana Commercial |
$586.50
|
| Rate for Payer: Humana KY Medicaid |
$237.29
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$239.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.20
|
| Rate for Payer: Ohio Health Group HMO |
$517.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$662.40
|
| Rate for Payer: United Healthcare All Payer |
$607.20
|
|
|
DURACLON [1MG] 1MG/10ML VIAL
|
Facility
|
IP
|
$187.34
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
25001961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.13
|
| Rate for Payer: Cash Price |
$93.67
|
| Rate for Payer: Cigna Commercial |
$155.49
|
| Rate for Payer: First Health Commercial |
$177.97
|
| Rate for Payer: Humana Commercial |
$159.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.86
|
| Rate for Payer: Ohio Health Group HMO |
$140.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.08
|
| Rate for Payer: PHCS Commercial |
$179.85
|
| Rate for Payer: United Healthcare All Payer |
$164.86
|
|
|
DURACLON [1MG] 1MG/10ML VIAL
|
Facility
|
OP
|
$187.34
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
25001961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Anthem Medicaid |
$64.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.13
|
| Rate for Payer: Cash Price |
$93.67
|
| Rate for Payer: Cigna Commercial |
$155.49
|
| Rate for Payer: First Health Commercial |
$177.97
|
| Rate for Payer: Humana Commercial |
$159.24
|
| Rate for Payer: Humana KY Medicaid |
$64.43
|
| Rate for Payer: Kentucky WC Medicaid |
$65.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.86
|
| Rate for Payer: Ohio Health Group HMO |
$140.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.08
|
| Rate for Payer: PHCS Commercial |
$179.85
|
| Rate for Payer: United Healthcare All Payer |
$164.86
|
|
|
DURAGESIC PTCH 12MCCG/FENTANYL
|
Facility
|
OP
|
$76.24
|
|
|
Service Code
|
NDC 406911276
|
| Hospital Charge Code |
25000586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$73.19 |
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem Medicaid |
$26.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.47
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.28
|
| Rate for Payer: First Health Commercial |
$72.43
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Humana KY Medicaid |
$26.22
|
| Rate for Payer: Kentucky WC Medicaid |
$26.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.09
|
| Rate for Payer: Ohio Health Group HMO |
$57.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.63
|
| Rate for Payer: PHCS Commercial |
$73.19
|
| Rate for Payer: United Healthcare All Payer |
$67.09
|
|
|
DURAGESIC PTCH 12MCCG/FENTANYL
|
Facility
|
IP
|
$76.24
|
|
|
Service Code
|
NDC 406911276
|
| Hospital Charge Code |
25000586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$73.19 |
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.47
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.28
|
| Rate for Payer: First Health Commercial |
$72.43
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.09
|
| Rate for Payer: Ohio Health Group HMO |
$57.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.63
|
| Rate for Payer: PHCS Commercial |
$73.19
|
| Rate for Payer: United Healthcare All Payer |
$67.09
|
|
|
DURALOC LOCK RING 58MM
|
Facility
|
IP
|
$4,062.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$528.11 |
| Max. Negotiated Rate |
$3,899.86 |
| Rate for Payer: Aetna Commercial |
$3,128.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.63
|
| Rate for Payer: Cash Price |
$2,031.17
|
| Rate for Payer: Cigna Commercial |
$3,371.75
|
| Rate for Payer: First Health Commercial |
$3,859.23
|
| Rate for Payer: Humana Commercial |
$3,453.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,574.87
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$812.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$528.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,259.33
|
| Rate for Payer: PHCS Commercial |
$3,899.86
|
| Rate for Payer: United Healthcare All Payer |
$3,574.87
|
|
|
DURALOC LOCK RING 58MM
|
Facility
|
OP
|
$4,062.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$528.11 |
| Max. Negotiated Rate |
$3,899.86 |
| Rate for Payer: Aetna Commercial |
$3,128.01
|
| Rate for Payer: Anthem Medicaid |
$1,397.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.63
|
| Rate for Payer: Cash Price |
$2,031.17
|
| Rate for Payer: Cigna Commercial |
$3,371.75
|
| Rate for Payer: First Health Commercial |
$3,859.23
|
| Rate for Payer: Humana Commercial |
$3,453.00
|
| Rate for Payer: Humana KY Medicaid |
$1,397.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,574.87
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$812.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$528.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,259.33
|
| Rate for Payer: PHCS Commercial |
$3,899.86
|
| Rate for Payer: United Healthcare All Payer |
$3,574.87
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$5,858.75
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
25003974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$5,624.40 |
| Rate for Payer: Aetna Commercial |
$4,511.24
|
| Rate for Payer: Anthem Medicaid |
$2,014.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,569.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.29
|
| Rate for Payer: Cash Price |
$2,929.38
|
| Rate for Payer: Cash Price |
$2,929.38
|
| Rate for Payer: Cigna Commercial |
$4,862.76
|
| Rate for Payer: First Health Commercial |
$5,565.81
|
| Rate for Payer: Humana Commercial |
$4,979.94
|
| Rate for Payer: Humana KY Medicaid |
$2,014.82
|
| Rate for Payer: Humana Medicare Advantage |
$6.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,035.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,804.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,323.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,055.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,155.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,394.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,171.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$761.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,816.21
|
| Rate for Payer: PHCS Commercial |
$5,624.40
|
| Rate for Payer: United Healthcare All Payer |
$5,155.70
|
|
