|
EVALUATE PT USE OF INHALER(T
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS 94664
|
| Hospital Charge Code |
761T2496
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.20
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
EVALUATION OF SWALLOWING
|
Facility
|
IP
|
$265.00
|
|
|
Service Code
|
HCPCS 92610
|
| Hospital Charge Code |
44000013
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$254.40 |
| Rate for Payer: Aetna Commercial |
$204.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$206.70
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$219.95
|
| Rate for Payer: First Health Commercial |
$251.75
|
| Rate for Payer: Humana Commercial |
$225.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$217.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$195.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$233.20
|
| Rate for Payer: Ohio Health Group HMO |
$198.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$212.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.85
|
| Rate for Payer: PHCS Commercial |
$254.40
|
| Rate for Payer: United Healthcare All Payer |
$233.20
|
|
|
EVALUATION OF SWALLOWING
|
Facility
|
OP
|
$265.00
|
|
|
Service Code
|
HCPCS 92610
|
| Hospital Charge Code |
44000013
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$79.50 |
| Max. Negotiated Rate |
$254.40 |
| Rate for Payer: Aetna Commercial |
$204.05
|
| Rate for Payer: Anthem Medicaid |
$91.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$206.70
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$219.95
|
| Rate for Payer: First Health Commercial |
$251.75
|
| Rate for Payer: Humana Commercial |
$225.25
|
| Rate for Payer: Humana KY Medicaid |
$91.13
|
| Rate for Payer: Kentucky WC Medicaid |
$92.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$217.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$195.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$92.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$233.20
|
| Rate for Payer: Ohio Health Group HMO |
$198.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$212.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.85
|
| Rate for Payer: PHCS Commercial |
$254.40
|
| Rate for Payer: United Healthcare All Payer |
$233.20
|
|
|
EVASC RPR A-AO NDGFT
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 34701
|
| Hospital Charge Code |
76101345
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.50 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,091.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$865.95
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
EVASC RPR A-AO NDGFT
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 34701
|
| Hospital Charge Code |
76101345
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.50 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem Medicaid |
$431.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Humana KY Medicaid |
$431.59
|
| Rate for Payer: Kentucky WC Medicaid |
$435.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$440.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,091.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$865.95
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
EVASC RPR A-AO NDGFT
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 34701
|
| Hospital Charge Code |
76101345
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$2,263.79 |
| Rate for Payer: Ambetter Exchange |
$1,159.03
|
| Rate for Payer: Anthem Medicaid |
$989.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,159.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,159.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,390.84
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$2,263.79
|
| Rate for Payer: Humana Medicaid |
$989.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,651.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,159.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,159.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,009.68
|
| Rate for Payer: Molina Healthcare Passport |
$989.88
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,506.74
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$999.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,159.03
|
|
|
EVASC RPR A-AO NDGFT(P
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 34701
|
| Hospital Charge Code |
761P1345
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$2,263.79 |
| Rate for Payer: Ambetter Exchange |
$1,159.03
|
| Rate for Payer: Anthem Medicaid |
$989.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,159.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,159.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,390.84
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$2,263.79
|
| Rate for Payer: Humana Medicaid |
$989.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,651.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,159.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,159.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,009.68
|
| Rate for Payer: Molina Healthcare Passport |
$989.88
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,506.74
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$999.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,159.03
|
|
|
EVASC RPR A-AO NDGFT RPT
|
Facility
|
OP
|
$2,090.00
|
|
|
Service Code
|
HCPCS 34702
|
| Hospital Charge Code |
76101346
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$627.00 |
| Max. Negotiated Rate |
$2,006.40 |
| Rate for Payer: Aetna Commercial |
$1,609.30
|
| Rate for Payer: Anthem Medicaid |
$718.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.20
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cigna Commercial |
$1,734.70
|
| Rate for Payer: First Health Commercial |
$1,985.50
|
| Rate for Payer: Humana Commercial |
$1,776.50
|
| Rate for Payer: Humana KY Medicaid |
$718.75
|
| Rate for Payer: Kentucky WC Medicaid |
$726.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,713.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$733.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.10
|
| Rate for Payer: PHCS Commercial |
$2,006.40
|
| Rate for Payer: United Healthcare All Payer |
$1,839.20
|
|
|
EVASC RPR A-AO NDGFT RPT
|
Facility
|
IP
|
$2,090.00
|
|
|
Service Code
|
HCPCS 34702
|
| Hospital Charge Code |
76101346
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$627.00 |
| Max. Negotiated Rate |
$2,006.40 |
| Rate for Payer: Aetna Commercial |
$1,609.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.20
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cigna Commercial |
$1,734.70
|
| Rate for Payer: First Health Commercial |
$1,985.50
|
| Rate for Payer: Humana Commercial |
$1,776.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,713.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.10
|
| Rate for Payer: PHCS Commercial |
$2,006.40
|
| Rate for Payer: United Healthcare All Payer |
$1,839.20
|
|
|
EVASC RPR A-AO NDGFT RPT
|
Professional
|
Both
|
$2,090.00
|
|
|
Service Code
|
HCPCS 34702
|
| Hospital Charge Code |
76101346
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$731.50 |
| Max. Negotiated Rate |
$3,384.08 |
| Rate for Payer: Ambetter Exchange |
$1,687.46
|
| Rate for Payer: Anthem Medicaid |
$1,480.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,687.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,687.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,024.95
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cigna Commercial |
$3,384.08
|
| Rate for Payer: Humana Medicaid |
$1,480.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,468.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,687.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,687.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,510.10
|
| Rate for Payer: Molina Healthcare Passport |
$1,480.49
|
| Rate for Payer: Multiplan PHCS |
$1,254.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,193.70
|
| Rate for Payer: UHCCP Medicaid |
$731.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,495.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,687.46
|
|
|
EVASC RPR A-AO NDGFT RPT(P
|
Professional
|
Both
|
$2,090.00
|
|
|
Service Code
|
HCPCS 34702
|
| Hospital Charge Code |
761P1346
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$731.50 |
| Max. Negotiated Rate |
$3,384.08 |
| Rate for Payer: Ambetter Exchange |
$1,687.46
|
| Rate for Payer: Anthem Medicaid |
$1,480.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,687.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,687.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,024.95
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cash Price |
$1,045.00
|
| Rate for Payer: Cigna Commercial |
$3,384.08
|
| Rate for Payer: Humana Medicaid |
$1,480.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,468.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,687.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,687.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,510.10
|
| Rate for Payer: Molina Healthcare Passport |
$1,480.49
|
| Rate for Payer: Multiplan PHCS |
$1,254.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,193.70
|
| Rate for Payer: UHCCP Medicaid |
$731.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,495.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,687.46
|
|
|
EVASC RPR A-BIILIAC RPT
|
Facility
|
IP
|
$2,575.00
|
|
|
Service Code
|
HCPCS 34706
|
| Hospital Charge Code |
76101348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$772.50 |
| Max. Negotiated Rate |
$2,472.00 |
| Rate for Payer: Aetna Commercial |
$1,982.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,008.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,137.25
|
| Rate for Payer: First Health Commercial |
$2,446.25
|
| Rate for Payer: Humana Commercial |
$2,188.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,111.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,900.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$772.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,266.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,931.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,060.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,240.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,776.75
|
| Rate for Payer: PHCS Commercial |
$2,472.00
|
| Rate for Payer: United Healthcare All Payer |
$2,266.00
|
|
|
EVASC RPR A-BIILIAC RPT
|
Professional
|
Both
|
$2,575.00
|
|
|
Service Code
|
HCPCS 34706
|
| Hospital Charge Code |
76101348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$901.25 |
| Max. Negotiated Rate |
$4,233.07 |
| Rate for Payer: Ambetter Exchange |
$2,136.50
|
| Rate for Payer: Anthem Medicaid |
$1,851.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,136.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,136.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,563.80
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$4,233.07
|
| Rate for Payer: Humana Medicaid |
$1,851.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,088.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,136.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,888.07
|
| Rate for Payer: Molina Healthcare Passport |
$1,851.05
|
| Rate for Payer: Multiplan PHCS |
$1,545.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,777.45
|
| Rate for Payer: UHCCP Medicaid |
$901.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,869.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,136.50
|
|
|
EVASC RPR A-BIILIAC RPT
|
Facility
|
OP
|
$2,575.00
|
|
|
Service Code
|
HCPCS 34706
|
| Hospital Charge Code |
76101348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$772.50 |
| Max. Negotiated Rate |
$2,472.00 |
| Rate for Payer: Aetna Commercial |
$1,982.75
|
| Rate for Payer: Anthem Medicaid |
$885.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,008.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$2,137.25
|
| Rate for Payer: First Health Commercial |
$2,446.25
|
| Rate for Payer: Humana Commercial |
$2,188.75
|
| Rate for Payer: Humana KY Medicaid |
$885.54
|
| Rate for Payer: Kentucky WC Medicaid |
$894.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,111.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,900.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$772.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$903.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,266.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,931.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,060.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,240.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,776.75
|
| Rate for Payer: PHCS Commercial |
$2,472.00
|
| Rate for Payer: United Healthcare All Payer |
$2,266.00
|
|
|
EVASC RPR A-BIILIAC RPT(P
|
Professional
|
Both
|
$2,575.00
|
|
|
Service Code
|
HCPCS 34706
|
| Hospital Charge Code |
761P1348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$901.25 |
| Max. Negotiated Rate |
$4,233.07 |
| Rate for Payer: Ambetter Exchange |
$2,136.50
|
| Rate for Payer: Anthem Medicaid |
$1,851.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,136.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,136.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,563.80
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$4,233.07
|
| Rate for Payer: Humana Medicaid |
$1,851.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,088.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,136.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,888.07
|
| Rate for Payer: Molina Healthcare Passport |
$1,851.05
|
| Rate for Payer: Multiplan PHCS |
$1,545.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,777.45
|
| Rate for Payer: UHCCP Medicaid |
$901.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,869.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,136.50
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
761P2609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$2,550.74 |
| Rate for Payer: Ambetter Exchange |
$1,285.44
|
| Rate for Payer: Anthem Medicaid |
$1,114.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,285.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,285.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,542.53
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$2,550.74
|
| Rate for Payer: Humana Medicaid |
$1,114.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,861.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,285.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,285.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,136.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,114.11
|
| Rate for Payer: Multiplan PHCS |
$978.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,671.07
|
| Rate for Payer: UHCCP Medicaid |
$570.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,125.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,285.44
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$2,550.74 |
| Rate for Payer: Ambetter Exchange |
$1,285.44
|
| Rate for Payer: Anthem Medicaid |
$1,114.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,285.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,285.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,542.53
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$2,550.74
|
| Rate for Payer: Humana Medicaid |
$1,114.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,861.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,285.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,285.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,136.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,114.11
|
| Rate for Payer: Multiplan PHCS |
$978.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,671.07
|
| Rate for Payer: UHCCP Medicaid |
$570.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,125.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,285.44
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Facility
|
IP
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.00 |
| Max. Negotiated Rate |
$1,564.80 |
| Rate for Payer: Aetna Commercial |
$1,255.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,271.40
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$1,352.90
|
| Rate for Payer: First Health Commercial |
$1,548.50
|
| Rate for Payer: Humana Commercial |
$1,385.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,336.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,202.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,434.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,418.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,124.70
|
| Rate for Payer: PHCS Commercial |
$1,564.80
|
| Rate for Payer: United Healthcare All Payer |
$1,434.40
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Facility
|
OP
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.00 |
| Max. Negotiated Rate |
$1,564.80 |
| Rate for Payer: Aetna Commercial |
$1,255.10
|
| Rate for Payer: Anthem Medicaid |
$560.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,271.40
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$1,352.90
|
| Rate for Payer: First Health Commercial |
$1,548.50
|
| Rate for Payer: Humana Commercial |
$1,385.50
|
| Rate for Payer: Humana KY Medicaid |
$560.56
|
| Rate for Payer: Kentucky WC Medicaid |
$566.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,336.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,202.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$571.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,434.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,418.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,124.70
|
| Rate for Payer: PHCS Commercial |
$1,564.80
|
| Rate for Payer: United Healthcare All Payer |
$1,434.40
|
|
|
EVASC RPR ILIO-ILIAC NDGFT
|
Professional
|
Both
|
$1,205.00
|
|
|
Service Code
|
HCPCS 34707
|
| Hospital Charge Code |
76102744
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.75 |
| Max. Negotiated Rate |
$2,111.83 |
| Rate for Payer: Ambetter Exchange |
$1,088.80
|
| Rate for Payer: Anthem Medicaid |
$923.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,088.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,088.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,306.56
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cigna Commercial |
$2,111.83
|
| Rate for Payer: Humana Medicaid |
$923.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,540.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,088.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,088.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$941.98
|
| Rate for Payer: Molina Healthcare Passport |
$923.51
|
| Rate for Payer: Multiplan PHCS |
$723.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,415.44
|
| Rate for Payer: UHCCP Medicaid |
$421.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$932.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,088.80
|
|
|
EVASC RPR N/A A-ILIAC NDGFT
|
Professional
|
Both
|
$1,450.00
|
|
|
Service Code
|
HCPCS 34718
|
| Hospital Charge Code |
76102727
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$507.50 |
| Max. Negotiated Rate |
$1,740.55 |
| Rate for Payer: Ambetter Exchange |
$1,158.28
|
| Rate for Payer: Anthem Medicaid |
$1,006.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,158.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,158.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,389.94
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Humana Medicaid |
$1,006.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,740.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,158.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,158.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,026.33
|
| Rate for Payer: Molina Healthcare Passport |
$1,006.21
|
| Rate for Payer: Multiplan PHCS |
$870.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,505.76
|
| Rate for Payer: UHCCP Medicaid |
$507.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,016.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,158.28
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
OP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
76102515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,364.94 |
| Max. Negotiated Rate |
$4,071.52 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem Medicaid |
$1,364.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Humana KY Medicaid |
$1,364.94
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,453.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.61
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
IP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
76102515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,190.70 |
| Max. Negotiated Rate |
$3,810.24 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,453.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.61
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
OP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
48100082
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,364.94 |
| Max. Negotiated Rate |
$4,071.52 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem Medicaid |
$1,364.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Humana KY Medicaid |
$1,364.94
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,453.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.61
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
IP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
48100082
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,190.70 |
| Max. Negotiated Rate |
$3,810.24 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,453.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.61
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
