|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$87.87
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
636T0118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$84.36 |
| Rate for Payer: Aetna Commercial |
$67.66
|
| Rate for Payer: Anthem Medicaid |
$30.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.29
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cigna Commercial |
$72.93
|
| Rate for Payer: First Health Commercial |
$83.48
|
| Rate for Payer: Humana Commercial |
$74.69
|
| Rate for Payer: Humana KY Medicaid |
$30.22
|
| Rate for Payer: Humana Medicare Advantage |
$6.14
|
| Rate for Payer: Kentucky WC Medicaid |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.33
|
| Rate for Payer: Ohio Health Group HMO |
$65.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.24
|
| Rate for Payer: PHCS Commercial |
$84.36
|
| Rate for Payer: United Healthcare All Payer |
$77.33
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$87.87
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
636T0118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$84.36 |
| Rate for Payer: Aetna Commercial |
$67.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.54
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cigna Commercial |
$72.93
|
| Rate for Payer: First Health Commercial |
$83.48
|
| Rate for Payer: Humana Commercial |
$74.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.33
|
| Rate for Payer: Ohio Health Group HMO |
$65.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.24
|
| Rate for Payer: PHCS Commercial |
$84.36
|
| Rate for Payer: United Healthcare All Payer |
$77.33
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$87.87
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$84.36 |
| Rate for Payer: Aetna Commercial |
$67.66
|
| Rate for Payer: Anthem Medicaid |
$30.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.29
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cigna Commercial |
$72.93
|
| Rate for Payer: First Health Commercial |
$83.48
|
| Rate for Payer: Humana Commercial |
$74.69
|
| Rate for Payer: Humana KY Medicaid |
$30.22
|
| Rate for Payer: Humana Medicare Advantage |
$6.14
|
| Rate for Payer: Kentucky WC Medicaid |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.33
|
| Rate for Payer: Ohio Health Group HMO |
$65.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.24
|
| Rate for Payer: PHCS Commercial |
$84.36
|
| Rate for Payer: United Healthcare All Payer |
$77.33
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$5,858.75
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
25003974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$761.64 |
| Max. Negotiated Rate |
$5,624.40 |
| Rate for Payer: Aetna Commercial |
$4,511.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,569.82
|
| 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: 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 |
$1,757.62
|
| 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
|
|
|
DUROLANE 1mg (60mg)
|
Professional
|
Both
|
$87.87
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.34 |
| Max. Negotiated Rate |
$87.87 |
| Rate for Payer: Aetna Commercial |
$21.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.87
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.43
|
| Rate for Payer: Multiplan PHCS |
$52.72
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.51
|
| Rate for Payer: UHCCP Medicaid |
$30.75
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$87.87
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.42 |
| Max. Negotiated Rate |
$84.36 |
| Rate for Payer: Aetna Commercial |
$67.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.54
|
| Rate for Payer: Cash Price |
$43.94
|
| Rate for Payer: Cigna Commercial |
$72.93
|
| Rate for Payer: First Health Commercial |
$83.48
|
| Rate for Payer: Humana Commercial |
$74.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.33
|
| Rate for Payer: Ohio Health Group HMO |
$65.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.24
|
| Rate for Payer: PHCS Commercial |
$84.36
|
| Rate for Payer: United Healthcare All Payer |
$77.33
|
|
|
DVX CATHETER
|
Facility
|
IP
|
$7,380.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$959.50 |
| Max. Negotiated Rate |
$7,085.52 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,052.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,495.06
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$959.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,288.03
|
| Rate for Payer: PHCS Commercial |
$7,085.52
|
| Rate for Payer: United Healthcare All Payer |
$6,495.06
|
| Rate for Payer: Aetna Commercial |
$5,683.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.98
|
| Rate for Payer: Cash Price |
$3,690.38
|
| Rate for Payer: Cigna Commercial |
$6,126.02
|
| Rate for Payer: First Health Commercial |
$7,011.71
|
| Rate for Payer: Humana Commercial |
$6,273.64
|
|
|
DVX CATHETER
|
Facility
|
OP
|
$7,380.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$959.50 |
| Max. Negotiated Rate |
$7,085.52 |
| Rate for Payer: Aetna Commercial |
$5,683.18
|
| Rate for Payer: Anthem Medicaid |
$2,538.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.98
|
| Rate for Payer: Cash Price |
$3,690.38
|
| Rate for Payer: Cigna Commercial |
$6,126.02
|
| Rate for Payer: First Health Commercial |
$7,011.71
|
| Rate for Payer: Humana Commercial |
$6,273.64
|
| Rate for Payer: Humana KY Medicaid |
$2,538.24
|
| Rate for Payer: Kentucky WC Medicaid |
$2,564.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,052.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,589.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,495.06
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$959.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,288.03
|
| Rate for Payer: PHCS Commercial |
$7,085.52
|
| Rate for Payer: United Healthcare All Payer |
$6,495.06
|
|
|
DX BRONCHOSCOPE/BRUSH
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS 31623
|
| Hospital Charge Code |
41000035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$66.97 |
| Max. Negotiated Rate |
$417.03 |
| Rate for Payer: Aetna Commercial |
$243.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.97
|
| Rate for Payer: Anthem Medicaid |
$127.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$371.00
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$222.18
|
| Rate for Payer: Healthspan PPO |
$417.03
|
| Rate for Payer: Humana Medicaid |
$127.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$188.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.77
|
| Rate for Payer: Molina Healthcare Passport |
$127.23
|
| Rate for Payer: Multiplan PHCS |
$222.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$259.70
|
| Rate for Payer: UHCCP Medicaid |
$70.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.50
|
|
|
DX BRONCHOSCOPE/BRUSH(P
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS 31623
|
| Hospital Charge Code |
410P0035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$66.97 |
| Max. Negotiated Rate |
$417.03 |
| Rate for Payer: Aetna Commercial |
$243.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.97
|
| Rate for Payer: Anthem Medicaid |
$127.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$371.00
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$222.18
|
| Rate for Payer: Healthspan PPO |
$417.03
|
| Rate for Payer: Humana Medicaid |
$127.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$188.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.77
|
| Rate for Payer: Molina Healthcare Passport |
$127.23
|
| Rate for Payer: Multiplan PHCS |
$222.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$259.70
|
| Rate for Payer: UHCCP Medicaid |
$70.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.50
|
|
|
DX BRONCHOSCOPE/LAVAGE
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 31624
|
| Hospital Charge Code |
41000036
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$67.66 |
| Max. Negotiated Rate |
$388.60 |
| Rate for Payer: Aetna Commercial |
$244.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.66
|
| Rate for Payer: Anthem Medicaid |
$128.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$222.18
|
| Rate for Payer: Healthspan PPO |
$388.60
|
| Rate for Payer: Humana Medicaid |
$128.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$189.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$131.21
|
| Rate for Payer: Molina Healthcare Passport |
$128.64
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$71.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.93
|
|
|
DX BRONCHOSCOPE/LAVAGE(P
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 31624
|
| Hospital Charge Code |
410P0036
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$67.66 |
| Max. Negotiated Rate |
$388.60 |
| Rate for Payer: Aetna Commercial |
$244.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.66
|
| Rate for Payer: Anthem Medicaid |
$128.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$222.18
|
| Rate for Payer: Healthspan PPO |
$388.60
|
| Rate for Payer: Humana Medicaid |
$128.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$189.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$131.21
|
| Rate for Payer: Molina Healthcare Passport |
$128.64
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$71.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.93
|
|
|
DX FIBERTAK SUTURE ANCHOR #2
|
Facility
|
OP
|
$4,386.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.26 |
| Max. Negotiated Rate |
$4,211.16 |
| Rate for Payer: Aetna Commercial |
$3,377.70
|
| Rate for Payer: Anthem Medicaid |
$1,508.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,421.56
|
| Rate for Payer: Cash Price |
$2,193.31
|
| Rate for Payer: Cigna Commercial |
$3,640.89
|
| Rate for Payer: First Health Commercial |
$4,167.29
|
| Rate for Payer: Humana Commercial |
$3,728.63
|
| Rate for Payer: Humana KY Medicaid |
$1,508.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,523.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,597.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,237.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,315.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,538.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,860.23
|
| Rate for Payer: Ohio Health Group HMO |
$3,289.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$877.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$570.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,359.85
|
| Rate for Payer: PHCS Commercial |
$4,211.16
|
| Rate for Payer: United Healthcare All Payer |
$3,860.23
|
|
|
DX FIBERTAK SUTURE ANCHOR #2
|
Facility
|
IP
|
$4,386.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.26 |
| Max. Negotiated Rate |
$4,211.16 |
| Rate for Payer: Aetna Commercial |
$3,377.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,421.56
|
| Rate for Payer: Cash Price |
$2,193.31
|
| Rate for Payer: Cigna Commercial |
$3,640.89
|
| Rate for Payer: First Health Commercial |
$4,167.29
|
| Rate for Payer: Humana Commercial |
$3,728.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,597.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,237.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,315.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,860.23
|
| Rate for Payer: Ohio Health Group HMO |
$3,289.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$877.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$570.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,359.85
|
| Rate for Payer: PHCS Commercial |
$4,211.16
|
| Rate for Payer: United Healthcare All Payer |
$3,860.23
|
|
|
DX LARYNGOSCOPY W/OPER SCOPE
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 31526
|
| Hospital Charge Code |
41000019
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$172.89 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Molina Healthcare Passport |
$172.89
|
| Rate for Payer: Aetna Commercial |
$238.78
|
| Rate for Payer: Anthem Medicaid |
$172.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$240.97
|
| Rate for Payer: Healthspan PPO |
$201.37
|
| Rate for Payer: Humana Medicaid |
$172.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$176.35
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.62
|
|
|
DX LARYNGOSCOPY W/OPER SCOP(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 31526
|
| Hospital Charge Code |
410P0019
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$172.89 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$238.78
|
| Rate for Payer: Anthem Medicaid |
$172.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$240.97
|
| Rate for Payer: Healthspan PPO |
$201.37
|
| Rate for Payer: Humana Medicaid |
$172.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$176.35
|
| Rate for Payer: Molina Healthcare Passport |
$172.89
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$174.62
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Professional
|
Both
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
36001289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.50 |
| Max. Negotiated Rate |
$1,198.00 |
| Rate for Payer: UHCCP Medicaid |
$76.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.18
|
| Rate for Payer: Anthem Medicaid |
$72.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,198.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Humana Medicaid |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.95
|
| Rate for Payer: Molina Healthcare Passport |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$718.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$838.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.22
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Facility
|
IP
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
76102742
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$1,150.08 |
| Rate for Payer: Aetna Commercial |
$922.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$934.44
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cigna Commercial |
$994.34
|
| Rate for Payer: First Health Commercial |
$1,138.10
|
| Rate for Payer: Humana Commercial |
$1,018.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$982.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,054.24
|
| Rate for Payer: Ohio Health Group HMO |
$898.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.38
|
| Rate for Payer: PHCS Commercial |
$1,150.08
|
| Rate for Payer: United Healthcare All Payer |
$1,054.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Facility
|
IP
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
36001289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$1,150.08 |
| Rate for Payer: Aetna Commercial |
$922.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$934.44
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cigna Commercial |
$994.34
|
| Rate for Payer: First Health Commercial |
$1,138.10
|
| Rate for Payer: Humana Commercial |
$1,018.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$982.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,054.24
|
| Rate for Payer: Ohio Health Group HMO |
$898.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.38
|
| Rate for Payer: PHCS Commercial |
$1,150.08
|
| Rate for Payer: United Healthcare All Payer |
$1,054.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Facility
|
OP
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
36001289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$1,150.08 |
| Rate for Payer: Aetna Commercial |
$922.46
|
| Rate for Payer: Anthem Medicaid |
$411.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$934.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cigna Commercial |
$994.34
|
| Rate for Payer: First Health Commercial |
$1,138.10
|
| Rate for Payer: Humana Commercial |
$1,018.30
|
| Rate for Payer: Humana KY Medicaid |
$411.99
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$416.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$982.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,054.24
|
| Rate for Payer: Ohio Health Group HMO |
$898.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.38
|
| Rate for Payer: PHCS Commercial |
$1,150.08
|
| Rate for Payer: United Healthcare All Payer |
$1,054.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Facility
|
OP
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
76102742
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.74 |
| Max. Negotiated Rate |
$1,150.08 |
| Rate for Payer: Aetna Commercial |
$922.46
|
| Rate for Payer: Anthem Medicaid |
$411.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$934.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cigna Commercial |
$994.34
|
| Rate for Payer: First Health Commercial |
$1,138.10
|
| Rate for Payer: Humana Commercial |
$1,018.30
|
| Rate for Payer: Humana KY Medicaid |
$411.99
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$416.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$982.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$884.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,054.24
|
| Rate for Payer: Ohio Health Group HMO |
$898.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.38
|
| Rate for Payer: PHCS Commercial |
$1,150.08
|
| Rate for Payer: United Healthcare All Payer |
$1,054.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT
|
Professional
|
Both
|
$1,198.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
76102742
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.50 |
| Max. Negotiated Rate |
$1,198.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.18
|
| Rate for Payer: Anthem Medicaid |
$72.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,198.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Cash Price |
$599.00
|
| Rate for Payer: Humana Medicaid |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.95
|
| Rate for Payer: Molina Healthcare Passport |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$718.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$838.60
|
| Rate for Payer: UHCCP Medicaid |
$76.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.22
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT (P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
360P1289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.18
|
| Rate for Payer: Anthem Medicaid |
$72.50
|
| 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: Humana Medicaid |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.95
|
| Rate for Payer: Molina Healthcare Passport |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$76.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.22
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT (P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
761P2742
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.18
|
| Rate for Payer: Anthem Medicaid |
$72.50
|
| 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: Humana Medicaid |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.95
|
| Rate for Payer: Molina Healthcare Passport |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$76.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.22
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT (T
|
Facility
|
OP
|
$948.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
360T1289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem Medicaid |
$326.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Humana KY Medicaid |
$326.02
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$329.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
