|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$2,880.33
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$2,765.12 |
| Rate for Payer: Aetna Commercial |
$2,217.85
|
| Rate for Payer: Anthem Medicaid |
$990.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,246.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$1,440.16
|
| Rate for Payer: Cash Price |
$1,440.16
|
| Rate for Payer: Cigna Commercial |
$2,390.67
|
| Rate for Payer: First Health Commercial |
$2,736.31
|
| Rate for Payer: Humana Commercial |
$2,448.28
|
| Rate for Payer: Humana KY Medicaid |
$990.55
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,000.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,361.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,125.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,010.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,534.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,160.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,304.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,505.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,987.43
|
| Rate for Payer: PHCS Commercial |
$2,765.12
|
| Rate for Payer: United Healthcare All Payer |
$2,534.69
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
IP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem Medicaid |
$16.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Humana KY Medicaid |
$16.50
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$4,798.73
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$4,606.78 |
| Rate for Payer: Aetna Commercial |
$3,695.02
|
| Rate for Payer: Anthem Medicaid |
$1,650.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,743.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$2,399.36
|
| Rate for Payer: Cash Price |
$2,399.36
|
| Rate for Payer: Cigna Commercial |
$3,982.95
|
| Rate for Payer: First Health Commercial |
$4,558.79
|
| Rate for Payer: Humana Commercial |
$4,078.92
|
| Rate for Payer: Humana KY Medicaid |
$1,650.28
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,667.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,541.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,683.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,599.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,174.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,311.12
|
| Rate for Payer: PHCS Commercial |
$4,606.78
|
| Rate for Payer: United Healthcare All Payer |
$4,222.88
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$4,798.73
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,439.62 |
| Max. Negotiated Rate |
$4,606.78 |
| Rate for Payer: Aetna Commercial |
$3,695.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,743.01
|
| Rate for Payer: Cash Price |
$2,399.36
|
| Rate for Payer: Cigna Commercial |
$3,982.95
|
| Rate for Payer: First Health Commercial |
$4,558.79
|
| Rate for Payer: Humana Commercial |
$4,078.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,541.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,599.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,174.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,311.12
|
| Rate for Payer: PHCS Commercial |
$4,606.78
|
| Rate for Payer: United Healthcare All Payer |
$4,222.88
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$46.07 |
| Rate for Payer: Aetna Commercial |
$36.95
|
| Rate for Payer: Anthem Medicaid |
$16.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.38
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.83
|
| Rate for Payer: First Health Commercial |
$45.59
|
| Rate for Payer: Humana Commercial |
$40.79
|
| Rate for Payer: Humana KY Medicaid |
$16.50
|
| Rate for Payer: Humana Medicare Advantage |
$9.17
|
| Rate for Payer: Kentucky WC Medicaid |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.23
|
| Rate for Payer: Ohio Health Group HMO |
$35.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.11
|
| Rate for Payer: PHCS Commercial |
$46.07
|
| Rate for Payer: United Healthcare All Payer |
$42.23
|
|
|
DYSPORT 5u (500u SDV)
|
Professional
|
Both
|
$47.99
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$28.79 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: Ambetter Exchange |
$9.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$9.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.17
|
| Rate for Payer: Multiplan PHCS |
$28.79
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.92
|
| Rate for Payer: UHCCP Medicaid |
$16.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.17
|
|
|
DYSPORT - AP
|
Professional
|
Both
|
$3.34
|
|
| Hospital Charge Code |
22200369
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Multiplan PHCS |
$2.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2.34
|
| Rate for Payer: UHCCP Medicaid |
$1.17
|
|
|
DYSPORT - AP
|
Facility
|
OP
|
$3.34
|
|
| Hospital Charge Code |
22200369
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: Anthem Medicaid |
$1.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.61
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.77
|
| Rate for Payer: First Health Commercial |
$3.17
|
| Rate for Payer: Humana Commercial |
$2.84
|
| Rate for Payer: Humana KY Medicaid |
$1.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.94
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.30
|
| Rate for Payer: PHCS Commercial |
$3.21
|
| Rate for Payer: United Healthcare All Payer |
$2.94
|
|
|
DYSPORT - AP
|
Facility
|
IP
|
$3.34
|
|
| Hospital Charge Code |
22200369
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.61
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cigna Commercial |
$2.77
|
| Rate for Payer: First Health Commercial |
$3.17
|
| Rate for Payer: Humana Commercial |
$2.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.94
|
| Rate for Payer: Ohio Health Group HMO |
$2.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.30
|
| Rate for Payer: PHCS Commercial |
$3.21
|
| Rate for Payer: United Healthcare All Payer |
$2.94
|
|
|
EACH ADD. BRONCHIAL STENT
|
Facility
|
OP
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
41000047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$123.97
|
| Rate for Payer: Anthem Medicaid |
$55.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$125.58
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$133.63
|
| Rate for Payer: First Health Commercial |
$152.95
|
| Rate for Payer: Humana Commercial |
$136.85
|
| Rate for Payer: Humana KY Medicaid |
$55.37
|
| Rate for Payer: Kentucky WC Medicaid |
$55.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$132.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$56.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$141.68
|
| Rate for Payer: Ohio Health Group HMO |
$120.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$140.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.09
|
| Rate for Payer: PHCS Commercial |
$154.56
|
| Rate for Payer: United Healthcare All Payer |
$141.68
|
|
|
EACH ADD. BRONCHIAL STENT
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
41000047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$154.56 |
| Rate for Payer: Aetna Commercial |
$123.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$125.58
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$133.63
|
| Rate for Payer: First Health Commercial |
$152.95
|
| Rate for Payer: Humana Commercial |
$136.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$132.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$141.68
|
| Rate for Payer: Ohio Health Group HMO |
$120.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$140.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.09
|
| Rate for Payer: PHCS Commercial |
$154.56
|
| Rate for Payer: United Healthcare All Payer |
$141.68
|
|
|
EACH ADD. BRONCHIAL STENT
|
Professional
|
Both
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
41000047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$135.11 |
| Rate for Payer: Aetna Commercial |
$135.11
|
| Rate for Payer: Ambetter Exchange |
$70.89
|
| Rate for Payer: Anthem Medicaid |
$64.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$70.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$70.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.07
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$123.57
|
| Rate for Payer: Healthspan PPO |
$105.49
|
| Rate for Payer: Humana Medicaid |
$64.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$70.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.82
|
| Rate for Payer: Molina Healthcare Passport |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$96.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$92.16
|
| Rate for Payer: UHCCP Medicaid |
$56.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$70.89
|
|
|
EACH ADD. BRONCHIAL STENT(P
|
Professional
|
Both
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
410P0047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$135.11 |
| Rate for Payer: Aetna Commercial |
$135.11
|
| Rate for Payer: Ambetter Exchange |
$70.89
|
| Rate for Payer: Anthem Medicaid |
$64.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$70.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$70.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.07
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$123.57
|
| Rate for Payer: Healthspan PPO |
$105.49
|
| Rate for Payer: Humana Medicaid |
$64.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$70.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.82
|
| Rate for Payer: Molina Healthcare Passport |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$96.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$92.16
|
| Rate for Payer: UHCCP Medicaid |
$56.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$70.89
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
IP
|
$3,668.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,100.40 |
| Max. Negotiated Rate |
$3,521.28 |
| Rate for Payer: Aetna Commercial |
$2,824.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,861.04
|
| Rate for Payer: Cash Price |
$1,834.00
|
| Rate for Payer: Cigna Commercial |
$3,044.44
|
| Rate for Payer: First Health Commercial |
$3,484.60
|
| Rate for Payer: Humana Commercial |
$3,117.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,007.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,706.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,100.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,227.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,751.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,934.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,191.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,530.92
|
| Rate for Payer: PHCS Commercial |
$3,521.28
|
| Rate for Payer: United Healthcare All Payer |
$3,227.84
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
IP
|
$2,508.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761T0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$752.40 |
| Max. Negotiated Rate |
$2,407.68 |
| Rate for Payer: Aetna Commercial |
$1,931.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,956.24
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$2,081.64
|
| Rate for Payer: First Health Commercial |
$2,382.60
|
| Rate for Payer: Humana Commercial |
$2,131.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,056.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,850.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,207.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,881.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,006.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,181.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,730.52
|
| Rate for Payer: PHCS Commercial |
$2,407.68
|
| Rate for Payer: United Healthcare All Payer |
$2,207.04
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Professional
|
Both
|
$3,668.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$414.37 |
| Max. Negotiated Rate |
$2,200.80 |
| Rate for Payer: Aetna Commercial |
$1,095.02
|
| Rate for Payer: Ambetter Exchange |
$663.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$414.37
|
| Rate for Payer: Anthem Medicaid |
$556.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$663.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$663.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$795.76
|
| Rate for Payer: Cash Price |
$1,834.00
|
| Rate for Payer: Cash Price |
$1,834.00
|
| Rate for Payer: Cigna Commercial |
$1,057.26
|
| Rate for Payer: Healthspan PPO |
$971.87
|
| Rate for Payer: Humana Medicaid |
$556.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$946.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$663.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$568.01
|
| Rate for Payer: Molina Healthcare Passport |
$556.87
|
| Rate for Payer: Multiplan PHCS |
$2,200.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$862.07
|
| Rate for Payer: UHCCP Medicaid |
$435.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$562.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$663.13
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
OP
|
$2,508.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761T0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$862.50 |
| Max. Negotiated Rate |
$2,407.68 |
| Rate for Payer: Aetna Commercial |
$1,931.16
|
| Rate for Payer: Anthem Medicaid |
$862.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,956.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cash Price |
$1,254.00
|
| Rate for Payer: Cigna Commercial |
$2,081.64
|
| Rate for Payer: First Health Commercial |
$2,382.60
|
| Rate for Payer: Humana Commercial |
$2,131.80
|
| Rate for Payer: Humana KY Medicaid |
$862.50
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$871.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,056.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,850.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$879.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,207.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,881.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,006.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,181.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,730.52
|
| Rate for Payer: PHCS Commercial |
$2,407.68
|
| Rate for Payer: United Healthcare All Payer |
$2,207.04
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761P0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$414.37 |
| Max. Negotiated Rate |
$1,095.02 |
| Rate for Payer: Aetna Commercial |
$1,095.02
|
| Rate for Payer: Ambetter Exchange |
$663.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$414.37
|
| Rate for Payer: Anthem Medicaid |
$556.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$663.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$663.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$795.76
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$1,057.26
|
| Rate for Payer: Healthspan PPO |
$971.87
|
| Rate for Payer: Humana Medicaid |
$556.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$946.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$663.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$568.01
|
| Rate for Payer: Molina Healthcare Passport |
$556.87
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$862.07
|
| Rate for Payer: UHCCP Medicaid |
$435.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$562.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$663.13
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
OP
|
$3,668.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,261.43 |
| Max. Negotiated Rate |
$3,521.28 |
| Rate for Payer: Aetna Commercial |
$2,824.36
|
| Rate for Payer: Anthem Medicaid |
$1,261.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,861.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,834.00
|
| Rate for Payer: Cash Price |
$1,834.00
|
| Rate for Payer: Cigna Commercial |
$3,044.44
|
| Rate for Payer: First Health Commercial |
$3,484.60
|
| Rate for Payer: Humana Commercial |
$3,117.80
|
| Rate for Payer: Humana KY Medicaid |
$1,261.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,007.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,706.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,286.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,227.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,751.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,934.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,191.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,530.92
|
| Rate for Payer: PHCS Commercial |
$3,521.28
|
| Rate for Payer: United Healthcare All Payer |
$3,227.84
|
|
|
EA FCE/NK/HF/G EA ADTL 100SQCM
|
Facility
|
IP
|
$1,095.00
|
|
|
Service Code
|
HCPCS 15116
|
| Hospital Charge Code |
76100180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$328.50 |
| Max. Negotiated Rate |
$1,051.20 |
| Rate for Payer: Aetna Commercial |
$843.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.10
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cigna Commercial |
$908.85
|
| Rate for Payer: First Health Commercial |
$1,040.25
|
| Rate for Payer: Humana Commercial |
$930.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$897.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$328.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$963.60
|
| Rate for Payer: Ohio Health Group HMO |
$821.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$876.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$952.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$755.55
|
| Rate for Payer: PHCS Commercial |
$1,051.20
|
| Rate for Payer: United Healthcare All Payer |
$963.60
|
|
|
EA FCE/NK/HF/G EA ADTL 100SQCM
|
Facility
|
OP
|
$1,095.00
|
|
|
Service Code
|
HCPCS 15116
|
| Hospital Charge Code |
76100180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$328.50 |
| Max. Negotiated Rate |
$1,051.20 |
| Rate for Payer: Aetna Commercial |
$843.15
|
| Rate for Payer: Anthem Medicaid |
$376.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.10
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cigna Commercial |
$908.85
|
| Rate for Payer: First Health Commercial |
$1,040.25
|
| Rate for Payer: Humana Commercial |
$930.75
|
| Rate for Payer: Humana KY Medicaid |
$376.57
|
| Rate for Payer: Kentucky WC Medicaid |
$380.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$897.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$328.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$384.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$963.60
|
| Rate for Payer: Ohio Health Group HMO |
$821.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$876.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$952.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$755.55
|
| Rate for Payer: PHCS Commercial |
$1,051.20
|
| Rate for Payer: United Healthcare All Payer |
$963.60
|
|
|
EAGLE EYE PLATINUM
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
