|
DRY NEEDLE 3+ MUS EA 15MIN OT
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS 20561
|
| Hospital Charge Code |
43000035
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$78.72 |
| Rate for Payer: Aetna Commercial |
$63.14
|
| Rate for Payer: Anthem Medicaid |
$28.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.55
|
| Rate for Payer: Cash Price |
$41.00
|
| Rate for Payer: Cash Price |
$41.00
|
| Rate for Payer: Cigna Commercial |
$68.06
|
| Rate for Payer: First Health Commercial |
$77.90
|
| Rate for Payer: Humana Commercial |
$69.70
|
| Rate for Payer: Humana KY Medicaid |
$28.20
|
| Rate for Payer: Humana Medicare Advantage |
$22.63
|
| Rate for Payer: Kentucky WC Medicaid |
$28.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.16
|
| Rate for Payer: Ohio Health Group HMO |
$61.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.58
|
| Rate for Payer: PHCS Commercial |
$78.72
|
| Rate for Payer: United Healthcare All Payer |
$72.16
|
|
|
DRY NEEDLE 3+ MUS EA 15MIN PT
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS 20561
|
| Hospital Charge Code |
42000062
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem Medicaid |
$28.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.55
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Humana KY Medicaid |
$28.89
|
| Rate for Payer: Humana Medicare Advantage |
$22.63
|
| Rate for Payer: Kentucky WC Medicaid |
$29.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
DRY NEEDLE 3+ MUS EA 15MIN PT
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS 20561
|
| Hospital Charge Code |
42000062
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.52
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
DRY SEAL SHEATH 26F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DRY SEAL SHEATH 26F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DSTRJ NULYT AGT GNCLR NRV
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
HCPCS 64624
|
| Hospital Charge Code |
76102922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
DSTRJ NULYT AGT GNCLR NRV
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 64624
|
| Hospital Charge Code |
76102922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.21 |
| Max. Negotiated Rate |
$314.14 |
| Rate for Payer: Ambetter Exchange |
$138.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.21
|
| Rate for Payer: Anthem Medicaid |
$307.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$138.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.67
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Humana Medicaid |
$307.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$189.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$138.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$314.14
|
| Rate for Payer: Molina Healthcare Passport |
$307.98
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.48
|
| Rate for Payer: UHCCP Medicaid |
$124.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$311.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.06
|
|
|
DSTRJ NULYT AGT GNCLR NRV
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
HCPCS 64624
|
| Hospital Charge Code |
76102922
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.36 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem Medicaid |
$120.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Humana KY Medicaid |
$120.36
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$121.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Facility
|
OP
|
$2,440.93
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
761T2358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,343.29 |
| Rate for Payer: Aetna Commercial |
$1,879.52
|
| Rate for Payer: Anthem Medicaid |
$839.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,903.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,220.46
|
| Rate for Payer: Cash Price |
$1,220.46
|
| Rate for Payer: Cigna Commercial |
$2,025.97
|
| Rate for Payer: First Health Commercial |
$2,318.88
|
| Rate for Payer: Humana Commercial |
$2,074.79
|
| Rate for Payer: Humana KY Medicaid |
$839.44
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$847.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,001.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,801.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$856.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,148.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,830.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,952.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,123.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,684.24
|
| Rate for Payer: PHCS Commercial |
$2,343.29
|
| Rate for Payer: United Healthcare All Payer |
$2,148.02
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Facility
|
IP
|
$2,440.93
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
761T2358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$732.28 |
| Max. Negotiated Rate |
$2,343.29 |
| Rate for Payer: Aetna Commercial |
$1,879.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,903.93
|
| Rate for Payer: Cash Price |
$1,220.46
|
| Rate for Payer: Cigna Commercial |
$2,025.97
|
| Rate for Payer: First Health Commercial |
$2,318.88
|
| Rate for Payer: Humana Commercial |
$2,074.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,001.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,801.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$732.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,148.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,830.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,952.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,123.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,684.24
|
| Rate for Payer: PHCS Commercial |
$2,343.29
|
| Rate for Payer: United Healthcare All Payer |
$2,148.02
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Facility
|
OP
|
$2,805.93
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
76102358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,693.69 |
| Rate for Payer: Aetna Commercial |
$2,160.57
|
| Rate for Payer: Anthem Medicaid |
$964.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,188.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,402.96
|
| Rate for Payer: Cash Price |
$1,402.96
|
| Rate for Payer: Cigna Commercial |
$2,328.92
|
| Rate for Payer: First Health Commercial |
$2,665.63
|
| Rate for Payer: Humana Commercial |
$2,385.04
|
| Rate for Payer: Humana KY Medicaid |
$964.96
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$974.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,300.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,070.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$984.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,469.22
|
| Rate for Payer: Ohio Health Group HMO |
$2,104.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,244.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,441.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,936.09
|
| Rate for Payer: PHCS Commercial |
$2,693.69
|
| Rate for Payer: United Healthcare All Payer |
$2,469.22
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Professional
|
Both
|
$365.00
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
761P2358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.67 |
| Max. Negotiated Rate |
$363.22 |
| Rate for Payer: Aetna Commercial |
$255.35
|
| Rate for Payer: Ambetter Exchange |
$151.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$81.67
|
| Rate for Payer: Anthem Medicaid |
$126.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$151.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$151.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.00
|
| Rate for Payer: Cash Price |
$182.50
|
| Rate for Payer: Cash Price |
$182.50
|
| Rate for Payer: Cigna Commercial |
$233.76
|
| Rate for Payer: Healthspan PPO |
$363.22
|
| Rate for Payer: Humana Medicaid |
$126.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$151.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.49
|
| Rate for Payer: Molina Healthcare Passport |
$126.95
|
| Rate for Payer: Multiplan PHCS |
$219.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$197.17
|
| Rate for Payer: UHCCP Medicaid |
$85.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$151.67
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Facility
|
IP
|
$2,805.93
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
76102358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$841.78 |
| Max. Negotiated Rate |
$2,693.69 |
| Rate for Payer: Aetna Commercial |
$2,160.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,188.63
|
| Rate for Payer: Cash Price |
$1,402.96
|
| Rate for Payer: Cigna Commercial |
$2,328.92
|
| Rate for Payer: First Health Commercial |
$2,665.63
|
| Rate for Payer: Humana Commercial |
$2,385.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,300.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,070.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$841.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,469.22
|
| Rate for Payer: Ohio Health Group HMO |
$2,104.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,244.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,441.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,936.09
|
| Rate for Payer: PHCS Commercial |
$2,693.69
|
| Rate for Payer: United Healthcare All Payer |
$2,469.22
|
|
|
DSTR NEURO WWORAD MONTCELCPLEX
|
Professional
|
Both
|
$2,805.93
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
76102358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.67 |
| Max. Negotiated Rate |
$1,683.56 |
| Rate for Payer: Aetna Commercial |
$255.35
|
| Rate for Payer: Ambetter Exchange |
$151.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$81.67
|
| Rate for Payer: Anthem Medicaid |
$126.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$151.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$151.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.00
|
| Rate for Payer: Cash Price |
$1,402.96
|
| Rate for Payer: Cash Price |
$1,402.96
|
| Rate for Payer: Cigna Commercial |
$233.76
|
| Rate for Payer: Healthspan PPO |
$363.22
|
| Rate for Payer: Humana Medicaid |
$126.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$151.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.49
|
| Rate for Payer: Molina Healthcare Passport |
$126.95
|
| Rate for Payer: Multiplan PHCS |
$1,683.56
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$197.17
|
| Rate for Payer: UHCCP Medicaid |
$85.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$151.67
|
|
|
DTAP .5ML
|
Facility
|
OP
|
$234.50
|
|
|
Service Code
|
HCPCS 90749
|
| Hospital Charge Code |
77000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.35 |
| Max. Negotiated Rate |
$225.12 |
| Rate for Payer: Aetna Commercial |
$180.56
|
| Rate for Payer: Anthem Medicaid |
$80.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.91
|
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Cigna Commercial |
$194.63
|
| Rate for Payer: First Health Commercial |
$222.78
|
| Rate for Payer: Humana Commercial |
$199.32
|
| Rate for Payer: Humana KY Medicaid |
$80.64
|
| Rate for Payer: Kentucky WC Medicaid |
$81.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.36
|
| Rate for Payer: Ohio Health Group HMO |
$175.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$187.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.81
|
| Rate for Payer: PHCS Commercial |
$225.12
|
| Rate for Payer: United Healthcare All Payer |
$206.36
|
|
|
DTAP .5ML
|
Professional
|
Both
|
$234.50
|
|
|
Service Code
|
HCPCS 90749
|
| Hospital Charge Code |
77000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$164.15 |
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$140.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.15
|
| Rate for Payer: UHCCP Medicaid |
$82.08
|
|
|
DTAP .5ML
|
Facility
|
IP
|
$234.50
|
|
|
Service Code
|
HCPCS 90749
|
| Hospital Charge Code |
77000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.35 |
| Max. Negotiated Rate |
$225.12 |
| Rate for Payer: Aetna Commercial |
$180.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.91
|
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Cigna Commercial |
$194.63
|
| Rate for Payer: First Health Commercial |
$222.78
|
| Rate for Payer: Humana Commercial |
$199.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.36
|
| Rate for Payer: Ohio Health Group HMO |
$175.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$187.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.81
|
| Rate for Payer: PHCS Commercial |
$225.12
|
| Rate for Payer: United Healthcare All Payer |
$206.36
|
|
|
DTAP .5ML(T
|
Facility
|
OP
|
$234.50
|
|
|
Service Code
|
HCPCS 90749
|
| Hospital Charge Code |
770T0054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.35 |
| Max. Negotiated Rate |
$225.12 |
| Rate for Payer: Aetna Commercial |
$180.56
|
| Rate for Payer: Anthem Medicaid |
$80.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.91
|
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Cigna Commercial |
$194.63
|
| Rate for Payer: First Health Commercial |
$222.78
|
| Rate for Payer: Humana Commercial |
$199.32
|
| Rate for Payer: Humana KY Medicaid |
$80.64
|
| Rate for Payer: Kentucky WC Medicaid |
$81.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.36
|
| Rate for Payer: Ohio Health Group HMO |
$175.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$187.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.81
|
| Rate for Payer: PHCS Commercial |
$225.12
|
| Rate for Payer: United Healthcare All Payer |
$206.36
|
|
|
DTAP .5ML(T
|
Facility
|
IP
|
$234.50
|
|
|
Service Code
|
HCPCS 90749
|
| Hospital Charge Code |
770T0054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.35 |
| Max. Negotiated Rate |
$225.12 |
| Rate for Payer: Aetna Commercial |
$180.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.91
|
| Rate for Payer: Cash Price |
$117.25
|
| Rate for Payer: Cigna Commercial |
$194.63
|
| Rate for Payer: First Health Commercial |
$222.78
|
| Rate for Payer: Humana Commercial |
$199.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.36
|
| Rate for Payer: Ohio Health Group HMO |
$175.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$187.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.81
|
| Rate for Payer: PHCS Commercial |
$225.12
|
| Rate for Payer: United Healthcare All Payer |
$206.36
|
|
|
DTAP/HEPB/IPV VACCINE
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
77000045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Humana KY Medicaid |
$101.11
|
| Rate for Payer: Kentucky WC Medicaid |
$102.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
DTAP/HEPB/IPV VACCINE
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
77000045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
DTAP/HEPB/IPV VACCINE
|
Professional
|
Both
|
$294.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
77000045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.72 |
| Max. Negotiated Rate |
$205.80 |
| Rate for Payer: Anthem Medicaid |
$70.72
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Healthspan PPO |
$70.84
|
| Rate for Payer: Humana Medicaid |
$70.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.13
|
| Rate for Payer: Molina Healthcare Passport |
$70.72
|
| Rate for Payer: Multiplan PHCS |
$176.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$205.80
|
| Rate for Payer: UHCCP Medicaid |
$102.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.43
|
|
|
DTAP/HEPB/IPV VACCINE(T
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
770T0045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
DTAP/HEPB/IPV VACCINE(T
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
770T0045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$282.24 |
| Rate for Payer: Aetna Commercial |
$226.38
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$229.32
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: Cigna Commercial |
$244.02
|
| Rate for Payer: First Health Commercial |
$279.30
|
| Rate for Payer: Humana Commercial |
$249.90
|
| Rate for Payer: Humana KY Medicaid |
$101.11
|
| Rate for Payer: Kentucky WC Medicaid |
$102.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$216.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$258.72
|
| Rate for Payer: Ohio Health Group HMO |
$220.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.86
|
| Rate for Payer: PHCS Commercial |
$282.24
|
| Rate for Payer: United Healthcare All Payer |
$258.72
|
|
|
DTAP - HIB - IPV
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
77000037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.63
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
