|
FERROUS GLUCONATE 3 325MG/1TAB
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 54629064501
|
| Hospital Charge Code |
25000674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
FERROUS GLUCONATE 3 325MG/1TAB
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 54629064501
|
| Hospital Charge Code |
25000674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
FERROUS SULFATE 300 300MG/5ML
|
Facility
|
IP
|
$11.39
|
|
|
Service Code
|
NDC 121053005
|
| Hospital Charge Code |
25000675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$10.93 |
| Rate for Payer: Aetna Commercial |
$8.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.88
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$9.45
|
| Rate for Payer: First Health Commercial |
$10.82
|
| Rate for Payer: Humana Commercial |
$9.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.02
|
| Rate for Payer: Ohio Health Group HMO |
$8.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| Rate for Payer: PHCS Commercial |
$10.93
|
| Rate for Payer: United Healthcare All Payer |
$10.02
|
|
|
FERROUS SULFATE 300 300MG/5ML
|
Facility
|
OP
|
$11.39
|
|
|
Service Code
|
NDC 121053005
|
| Hospital Charge Code |
25000675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$10.93 |
| Rate for Payer: Aetna Commercial |
$8.77
|
| Rate for Payer: Anthem Medicaid |
$3.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.88
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$9.45
|
| Rate for Payer: First Health Commercial |
$10.82
|
| Rate for Payer: Humana Commercial |
$9.68
|
| Rate for Payer: Humana KY Medicaid |
$3.92
|
| Rate for Payer: Kentucky WC Medicaid |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.02
|
| Rate for Payer: Ohio Health Group HMO |
$8.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.53
|
| Rate for Payer: PHCS Commercial |
$10.93
|
| Rate for Payer: United Healthcare All Payer |
$10.02
|
|
|
FETAL BIOPHYS PROFILE W/NST
|
Professional
|
Both
|
$660.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
40200041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$65.87 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna Commercial |
$185.82
|
| Rate for Payer: Anthem Medicaid |
$76.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$660.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$176.49
|
| Rate for Payer: Healthspan PPO |
$174.12
|
| Rate for Payer: Humana Medicaid |
$76.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.47
|
| Rate for Payer: Molina Healthcare Passport |
$76.93
|
| Rate for Payer: Multiplan PHCS |
$396.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$462.00
|
| Rate for Payer: UHCCP Medicaid |
$231.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.70
|
|
|
FETAL BIOPHYS PROFILE W/NST
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
40200041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
FETAL BIOPHYS PROFILE W/NST
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
40200041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
FETAL BIOPHYS PROFILE W/NST(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
402P0041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$65.87 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$185.82
|
| Rate for Payer: Anthem Medicaid |
$76.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$176.49
|
| Rate for Payer: Healthspan PPO |
$174.12
|
| Rate for Payer: Humana Medicaid |
$76.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.47
|
| Rate for Payer: Molina Healthcare Passport |
$76.93
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.70
|
|
|
FETAL BIOPHYS PROFILE W/NST(T
|
Facility
|
OP
|
$460.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
402T0041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem Medicaid |
$158.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Humana KY Medicaid |
$158.19
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$159.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.60
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
FETAL BIOPHYS PROFILE W/NST(T
|
Facility
|
IP
|
$460.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
402T0041
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.60
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
FETAL BIOPHYS PROFIL W/O NS(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
402P0042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$147.92 |
| Rate for Payer: Aetna Commercial |
$144.15
|
| Rate for Payer: Anthem Medicaid |
$68.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$147.92
|
| Rate for Payer: Healthspan PPO |
$135.08
|
| Rate for Payer: Humana Medicaid |
$68.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.75
|
| Rate for Payer: Molina Healthcare Passport |
$68.38
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.06
|
|
|
FETAL BIOPHYS PROFIL W/O NS(T
|
Facility
|
OP
|
$460.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
402T0042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem Medicaid |
$158.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Humana KY Medicaid |
$158.19
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$159.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.60
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
FETAL BIOPHYS PROFIL W/O NS(T
|
Facility
|
IP
|
$460.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
402T0042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$59.80 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.60
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
FETAL BIOPHYS PROFIL W/O NST
|
Facility
|
OP
|
$560.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
40200042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$537.60 |
| Rate for Payer: Aetna Commercial |
$431.20
|
| Rate for Payer: Anthem Medicaid |
$192.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$464.80
|
| Rate for Payer: First Health Commercial |
$532.00
|
| Rate for Payer: Humana Commercial |
$476.00
|
| Rate for Payer: Humana KY Medicaid |
$192.58
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$194.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$459.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$413.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.80
|
| Rate for Payer: Ohio Health Group HMO |
$420.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.60
|
| Rate for Payer: PHCS Commercial |
$537.60
|
| Rate for Payer: United Healthcare All Payer |
$492.80
|
|
|
FETAL BIOPHYS PROFIL W/O NST
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
40200042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$48.74 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Aetna Commercial |
$144.15
|
| Rate for Payer: Anthem Medicaid |
$68.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$560.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$147.92
|
| Rate for Payer: Healthspan PPO |
$135.08
|
| Rate for Payer: Humana Medicaid |
$68.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.75
|
| Rate for Payer: Molina Healthcare Passport |
$68.38
|
| Rate for Payer: Multiplan PHCS |
$336.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$392.00
|
| Rate for Payer: UHCCP Medicaid |
$196.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.06
|
|
|
FETAL BIOPHYS PROFIL W/O NST
|
Facility
|
IP
|
$560.00
|
|
|
Service Code
|
HCPCS 76819
|
| Hospital Charge Code |
40200042
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$537.60 |
| Rate for Payer: Aetna Commercial |
$431.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.80
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$464.80
|
| Rate for Payer: First Health Commercial |
$532.00
|
| Rate for Payer: Humana Commercial |
$476.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$459.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$413.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$492.80
|
| Rate for Payer: Ohio Health Group HMO |
$420.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$173.60
|
| Rate for Payer: PHCS Commercial |
$537.60
|
| Rate for Payer: United Healthcare All Payer |
$492.80
|
|
|
FETAL FIBRONECTIN
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
30000320
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$409.53
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
FETAL FIBRONECTIN
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
HCPCS 82731
|
| Hospital Charge Code |
30000320
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.41 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem Medicaid |
$64.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$64.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$409.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$90.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$64.41
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Humana KY Medicaid |
$64.41
|
| Rate for Payer: Humana Medicare Advantage |
$64.41
|
| Rate for Payer: Kentucky WC Medicaid |
$65.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
FETAL HBG DETCT FMH KLEIHA-BET
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS 85460
|
| Hospital Charge Code |
30000608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.73 |
| Max. Negotiated Rate |
$159.36 |
| Rate for Payer: Aetna Commercial |
$127.82
|
| Rate for Payer: Anthem Medicaid |
$7.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.73
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: First Health Commercial |
$157.70
|
| Rate for Payer: Humana Commercial |
$141.10
|
| Rate for Payer: Humana KY Medicaid |
$7.73
|
| Rate for Payer: Humana Medicare Advantage |
$7.73
|
| Rate for Payer: Kentucky WC Medicaid |
$7.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.08
|
| Rate for Payer: Ohio Health Group HMO |
$124.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.46
|
| Rate for Payer: PHCS Commercial |
$159.36
|
| Rate for Payer: United Healthcare All Payer |
$146.08
|
|
|
FETAL HBG DETCT FMH KLEIHA-BET
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS 85460
|
| Hospital Charge Code |
30000608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$159.36 |
| Rate for Payer: Aetna Commercial |
$127.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.30
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: First Health Commercial |
$157.70
|
| Rate for Payer: Humana Commercial |
$141.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.08
|
| Rate for Payer: Ohio Health Group HMO |
$124.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.46
|
| Rate for Payer: PHCS Commercial |
$159.36
|
| Rate for Payer: United Healthcare All Payer |
$146.08
|
|
|
FETAL HGB DETECT FMH ROSETTE
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS 85461
|
| Hospital Charge Code |
30000609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.42
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
FETAL HGB DETECT FMH ROSETTE
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS 85461
|
| Hospital Charge Code |
30000609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem Medicaid |
$9.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Humana KY Medicaid |
$9.36
|
| Rate for Payer: Humana Medicare Advantage |
$9.36
|
| Rate for Payer: Kentucky WC Medicaid |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
FETAL NON-STRESS TEST
|
Facility
|
OP
|
$605.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
92000004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$78.65 |
| Max. Negotiated Rate |
$580.80 |
| Rate for Payer: Aetna Commercial |
$465.85
|
| Rate for Payer: Anthem Medicaid |
$208.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$172.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$241.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.63
|
| Rate for Payer: Cash Price |
$302.50
|
| Rate for Payer: Cash Price |
$302.50
|
| Rate for Payer: Cigna Commercial |
$502.15
|
| Rate for Payer: First Health Commercial |
$574.75
|
| Rate for Payer: Humana Commercial |
$514.25
|
| Rate for Payer: Humana KY Medicaid |
$208.06
|
| Rate for Payer: Humana Medicare Advantage |
$172.32
|
| Rate for Payer: Kentucky WC Medicaid |
$210.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$496.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$446.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$212.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$532.40
|
| Rate for Payer: Ohio Health Group HMO |
$453.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.55
|
| Rate for Payer: PHCS Commercial |
$580.80
|
| Rate for Payer: United Healthcare All Payer |
$532.40
|
|
|
FETAL NON-STRESS TEST
|
Professional
|
Both
|
$605.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
92000004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$34.83 |
| Max. Negotiated Rate |
$605.00 |
| Rate for Payer: Aetna Commercial |
$75.93
|
| Rate for Payer: Anthem Medicaid |
$34.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$605.00
|
| Rate for Payer: Cash Price |
$302.50
|
| Rate for Payer: Cash Price |
$302.50
|
| Rate for Payer: Cigna Commercial |
$65.52
|
| Rate for Payer: Healthspan PPO |
$55.11
|
| Rate for Payer: Humana Medicaid |
$34.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.53
|
| Rate for Payer: Molina Healthcare Passport |
$34.83
|
| Rate for Payer: Multiplan PHCS |
$363.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$423.50
|
| Rate for Payer: UHCCP Medicaid |
$211.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.18
|
|
|
FETAL NON-STRESS TEST
|
Facility
|
IP
|
$605.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
92000004
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$78.65 |
| Max. Negotiated Rate |
$580.80 |
| Rate for Payer: Aetna Commercial |
$465.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.90
|
| Rate for Payer: Cash Price |
$302.50
|
| Rate for Payer: Cigna Commercial |
$502.15
|
| Rate for Payer: First Health Commercial |
$574.75
|
| Rate for Payer: Humana Commercial |
$514.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$496.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$446.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$181.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$532.40
|
| Rate for Payer: Ohio Health Group HMO |
$453.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.55
|
| Rate for Payer: PHCS Commercial |
$580.80
|
| Rate for Payer: United Healthcare All Payer |
$532.40
|
|
