|
DTAP - HIB - IPV
|
Facility
|
OP
|
$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 Medicaid |
$112.46
|
| 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: Humana KY Medicaid |
$112.46
|
| Rate for Payer: Kentucky WC Medicaid |
$113.60
|
| 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: Molina Healthcare Medicaid |
$114.71
|
| 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
|
|
|
DTAP - HIB - IPV
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
77000037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.86 |
| Max. Negotiated Rate |
$228.90 |
| Rate for Payer: Anthem Medicaid |
$70.72
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Healthspan PPO |
$50.86
|
| Rate for Payer: Humana Medicaid |
$70.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$220.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.13
|
| Rate for Payer: Molina Healthcare Passport |
$70.72
|
| Rate for Payer: Multiplan PHCS |
$196.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$228.90
|
| Rate for Payer: UHCCP Medicaid |
$114.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.43
|
|
|
DTAP - HIB - IPV(T
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
770T0037
|
|
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
|
|
|
DTAP - HIB - IPV(T
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 90698
|
| Hospital Charge Code |
770T0037
|
|
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 Medicaid |
$112.46
|
| 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: Humana KY Medicaid |
$112.46
|
| Rate for Payer: Kentucky WC Medicaid |
$113.60
|
| 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: Molina Healthcare Medicaid |
$114.71
|
| 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
|
|
|
DTAP-IPV
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
77000036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
DTAP-IPV
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
77000036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Anthem Medicaid |
$48.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$48.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.96
|
| Rate for Payer: Molina Healthcare Passport |
$48.00
|
| Rate for Payer: Multiplan PHCS |
$115.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$134.40
|
| Rate for Payer: UHCCP Medicaid |
$67.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.48
|
|
|
DTAP-IPV
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
77000036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem Medicaid |
$66.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Humana KY Medicaid |
$66.03
|
| Rate for Payer: Kentucky WC Medicaid |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
DTAP-IPV(T
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
770T0036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
DTAP-IPV(T
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 90696
|
| Hospital Charge Code |
770T0036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem Medicaid |
$66.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Humana KY Medicaid |
$66.03
|
| Rate for Payer: Kentucky WC Medicaid |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
DTAP VAC
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
77000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem Medicaid |
$53.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Humana KY Medicaid |
$53.65
|
| Rate for Payer: Kentucky WC Medicaid |
$54.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
DTAP VAC
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
77000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.47 |
| Max. Negotiated Rate |
$109.20 |
| Rate for Payer: Anthem Medicaid |
$23.47
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Humana Medicaid |
$23.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$23.94
|
| Rate for Payer: Molina Healthcare Passport |
$23.47
|
| Rate for Payer: Multiplan PHCS |
$93.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$109.20
|
| Rate for Payer: UHCCP Medicaid |
$54.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$23.70
|
|
|
DTAP VAC
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
77000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
DTAP VAC(T
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
770T0038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem Medicaid |
$53.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Humana KY Medicaid |
$53.65
|
| Rate for Payer: Kentucky WC Medicaid |
$54.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
DTAP VAC(T
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
770T0038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.68
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
DUCK FEATHERS IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000712
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DUCK FEATHERS IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000712
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$670.08 |
| Rate for Payer: Aetna Commercial |
$537.46
|
| Rate for Payer: Anthem Medicaid |
$240.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$544.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$579.34
|
| Rate for Payer: First Health Commercial |
$663.10
|
| Rate for Payer: Humana Commercial |
$593.30
|
| Rate for Payer: Humana KY Medicaid |
$240.04
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$242.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$572.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$515.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$244.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$614.24
|
| Rate for Payer: Ohio Health Group HMO |
$523.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$558.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$607.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$481.62
|
| Rate for Payer: PHCS Commercial |
$670.08
|
| Rate for Payer: United Healthcare All Payer |
$614.24
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$209.40 |
| Max. Negotiated Rate |
$670.08 |
| Rate for Payer: Aetna Commercial |
$537.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$544.44
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$579.34
|
| Rate for Payer: First Health Commercial |
$663.10
|
| Rate for Payer: Humana Commercial |
$593.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$572.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$515.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$209.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$614.24
|
| Rate for Payer: Ohio Health Group HMO |
$523.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$558.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$607.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$481.62
|
| Rate for Payer: PHCS Commercial |
$670.08
|
| Rate for Payer: United Healthcare All Payer |
$614.24
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Professional
|
Both
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$29.03 |
| Max. Negotiated Rate |
$418.80 |
| Rate for Payer: Aetna Commercial |
$159.20
|
| Rate for Payer: Ambetter Exchange |
$62.71
|
| Rate for Payer: Anthem Medicaid |
$100.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.25
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$214.74
|
| Rate for Payer: Healthspan PPO |
$149.18
|
| Rate for Payer: Humana Medicaid |
$100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.77
|
| Rate for Payer: Molina Healthcare Passport |
$100.75
|
| Rate for Payer: Multiplan PHCS |
$418.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$81.52
|
| Rate for Payer: UHCCP Medicaid |
$244.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.71
|
|
|
DUCTOGRAM MULTI DUCT S&I(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402P0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$214.74 |
| Rate for Payer: Aetna Commercial |
$159.20
|
| Rate for Payer: Ambetter Exchange |
$62.71
|
| Rate for Payer: Anthem Medicaid |
$100.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$214.74
|
| Rate for Payer: Healthspan PPO |
$149.18
|
| Rate for Payer: Humana Medicaid |
$100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.77
|
| Rate for Payer: Molina Healthcare Passport |
$100.75
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$81.52
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.71
|
|
|
DUCTOGRAM MULTI DUCT S&I(T
|
Facility
|
IP
|
$623.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402T0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$186.90 |
| Max. Negotiated Rate |
$598.08 |
| Rate for Payer: Aetna Commercial |
$479.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$485.94
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cigna Commercial |
$517.09
|
| Rate for Payer: First Health Commercial |
$591.85
|
| Rate for Payer: Humana Commercial |
$529.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$510.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$459.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$548.24
|
| Rate for Payer: Ohio Health Group HMO |
$467.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$542.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$429.87
|
| Rate for Payer: PHCS Commercial |
$598.08
|
| Rate for Payer: United Healthcare All Payer |
$548.24
|
|
|
DUCTOGRAM MULTI DUCT S&I(T
|
Facility
|
OP
|
$623.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402T0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$214.25 |
| Max. Negotiated Rate |
$598.08 |
| Rate for Payer: Aetna Commercial |
$479.71
|
| Rate for Payer: Anthem Medicaid |
$214.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$485.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cigna Commercial |
$517.09
|
| Rate for Payer: First Health Commercial |
$591.85
|
| Rate for Payer: Humana Commercial |
$529.55
|
| Rate for Payer: Humana KY Medicaid |
$214.25
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$216.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$510.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$459.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$218.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$548.24
|
| Rate for Payer: Ohio Health Group HMO |
$467.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$542.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$429.87
|
| Rate for Payer: PHCS Commercial |
$598.08
|
| Rate for Payer: United Healthcare All Payer |
$548.24
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$22.39 |
| Max. Negotiated Rate |
$405.60 |
| Rate for Payer: Aetna Commercial |
$118.33
|
| Rate for Payer: Ambetter Exchange |
$48.60
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.32
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$149.83
|
| Rate for Payer: Healthspan PPO |
$110.88
|
| Rate for Payer: Humana Medicaid |
$70.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.91
|
| Rate for Payer: Molina Healthcare Passport |
$70.50
|
| Rate for Payer: Multiplan PHCS |
$405.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.18
|
| Rate for Payer: UHCCP Medicaid |
$236.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.20
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.60
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Facility
|
OP
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem Medicaid |
$232.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Humana KY Medicaid |
$232.48
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$234.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$237.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$466.44
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Facility
|
IP
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$202.80 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$466.44
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
