|
KETAMINE 500MG/5ML VIAL(5ML)
|
Facility
|
IP
|
$87.74
|
|
|
Service Code
|
NDC 409205115
|
| Hospital Charge Code |
25003148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$84.23 |
| Rate for Payer: Aetna Commercial |
$67.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.44
|
| Rate for Payer: Cash Price |
$43.87
|
| Rate for Payer: Cigna Commercial |
$72.82
|
| Rate for Payer: First Health Commercial |
$83.35
|
| Rate for Payer: Humana Commercial |
$74.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.21
|
| Rate for Payer: Ohio Health Group HMO |
$65.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.54
|
| Rate for Payer: PHCS Commercial |
$84.23
|
| Rate for Payer: United Healthcare All Payer |
$77.21
|
|
|
KETAMINE 500MG/5ML VIAL(5ML)
|
Facility
|
OP
|
$87.74
|
|
|
Service Code
|
NDC 409205115
|
| Hospital Charge Code |
25003148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$84.23 |
| Rate for Payer: Aetna Commercial |
$67.56
|
| Rate for Payer: Anthem Medicaid |
$30.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.44
|
| Rate for Payer: Cash Price |
$43.87
|
| Rate for Payer: Cigna Commercial |
$72.82
|
| Rate for Payer: First Health Commercial |
$83.35
|
| Rate for Payer: Humana Commercial |
$74.58
|
| Rate for Payer: Humana KY Medicaid |
$30.17
|
| Rate for Payer: Kentucky WC Medicaid |
$30.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$77.21
|
| Rate for Payer: Ohio Health Group HMO |
$65.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$70.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.54
|
| Rate for Payer: PHCS Commercial |
$84.23
|
| Rate for Payer: United Healthcare All Payer |
$77.21
|
|
|
KETAMINE 50MG/5ML SYRINGE
|
Facility
|
IP
|
$78.47
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003149
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$23.54 |
| Max. Negotiated Rate |
$75.33 |
| Rate for Payer: Aetna Commercial |
$60.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.21
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Cigna Commercial |
$65.13
|
| Rate for Payer: First Health Commercial |
$74.55
|
| Rate for Payer: Humana Commercial |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.05
|
| Rate for Payer: Ohio Health Group HMO |
$58.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.14
|
| Rate for Payer: PHCS Commercial |
$75.33
|
| Rate for Payer: United Healthcare All Payer |
$69.05
|
|
|
KETAMINE 50MG/5ML SYRINGE
|
Facility
|
OP
|
$78.47
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003149
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$23.54 |
| Max. Negotiated Rate |
$75.33 |
| Rate for Payer: Aetna Commercial |
$60.42
|
| Rate for Payer: Anthem Medicaid |
$26.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.21
|
| Rate for Payer: Cash Price |
$39.24
|
| Rate for Payer: Cigna Commercial |
$65.13
|
| Rate for Payer: First Health Commercial |
$74.55
|
| Rate for Payer: Humana Commercial |
$66.70
|
| Rate for Payer: Humana KY Medicaid |
$26.99
|
| Rate for Payer: Kentucky WC Medicaid |
$27.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.05
|
| Rate for Payer: Ohio Health Group HMO |
$58.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.14
|
| Rate for Payer: PHCS Commercial |
$75.33
|
| Rate for Payer: United Healthcare All Payer |
$69.05
|
|
|
KETOCONAZOLE 2% Cream 15g
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004472
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.68
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.98
|
| Rate for Payer: First Health Commercial |
$5.70
|
| Rate for Payer: Humana Commercial |
$5.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.28
|
| Rate for Payer: Ohio Health Group HMO |
$4.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.14
|
| Rate for Payer: PHCS Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Payer |
$5.28
|
|
|
KETOCONAZOLE 2% Cream 15g
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004472
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Aetna Commercial |
$4.62
|
| Rate for Payer: Anthem Medicaid |
$2.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.68
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$4.98
|
| Rate for Payer: First Health Commercial |
$5.70
|
| Rate for Payer: Humana Commercial |
$5.10
|
| Rate for Payer: Humana KY Medicaid |
$2.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.28
|
| Rate for Payer: Ohio Health Group HMO |
$4.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.14
|
| Rate for Payer: PHCS Commercial |
$5.76
|
| Rate for Payer: United Healthcare All Payer |
$5.28
|
|
|
KETOROLAC 15mg/1mL SDV
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
25004283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.93 |
| Max. Negotiated Rate |
$76.56 |
| Rate for Payer: Aetna Commercial |
$61.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.20
|
| Rate for Payer: Cash Price |
$39.88
|
| Rate for Payer: Cigna Commercial |
$66.19
|
| Rate for Payer: First Health Commercial |
$75.76
|
| Rate for Payer: Humana Commercial |
$67.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.18
|
| Rate for Payer: Ohio Health Group HMO |
$59.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.03
|
| Rate for Payer: PHCS Commercial |
$76.56
|
| Rate for Payer: United Healthcare All Payer |
$70.18
|
|
|
KETOROLAC 15mg/1mL SDV
|
Facility
|
OP
|
$79.75
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
25004283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$76.56 |
| Rate for Payer: Aetna Commercial |
$61.41
|
| Rate for Payer: Anthem Medicaid |
$27.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.43
|
| Rate for Payer: Cash Price |
$39.88
|
| Rate for Payer: Cash Price |
$39.88
|
| Rate for Payer: Cigna Commercial |
$66.19
|
| Rate for Payer: First Health Commercial |
$75.76
|
| Rate for Payer: Humana Commercial |
$67.79
|
| Rate for Payer: Humana KY Medicaid |
$27.43
|
| Rate for Payer: Humana Medicare Advantage |
$0.32
|
| Rate for Payer: Kentucky WC Medicaid |
$27.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.18
|
| Rate for Payer: Ohio Health Group HMO |
$59.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.03
|
| Rate for Payer: PHCS Commercial |
$76.56
|
| Rate for Payer: United Healthcare All Payer |
$70.18
|
|
|
KETOTIFEN FUMARATE 0.025% 10ML
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 24208060110
|
| Hospital Charge Code |
25003150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
KETOTIFEN FUMARATE 0.025% 10ML
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 24208060110
|
| Hospital Charge Code |
25003150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
KEYTRUDA 100MG/4ML VIAL
|
Facility
|
IP
|
$30,894.31
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
25002657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,268.29 |
| Max. Negotiated Rate |
$29,658.54 |
| Rate for Payer: Aetna Commercial |
$23,788.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,097.56
|
| Rate for Payer: Cash Price |
$15,447.16
|
| Rate for Payer: Cigna Commercial |
$25,642.28
|
| Rate for Payer: First Health Commercial |
$29,349.59
|
| Rate for Payer: Humana Commercial |
$26,260.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,333.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,800.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,268.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,186.99
|
| Rate for Payer: Ohio Health Group HMO |
$23,170.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,715.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,878.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,317.07
|
| Rate for Payer: PHCS Commercial |
$29,658.54
|
| Rate for Payer: United Healthcare All Payer |
$27,186.99
|
|
|
KEYTRUDA 100MG/4ML VIAL
|
Facility
|
OP
|
$30,894.31
|
|
|
Service Code
|
HCPCS J9271
|
| Hospital Charge Code |
25002657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.56 |
| Max. Negotiated Rate |
$29,658.54 |
| Rate for Payer: Aetna Commercial |
$23,788.62
|
| Rate for Payer: Anthem Medicaid |
$10,624.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$58.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,097.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$81.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$79.06
|
| Rate for Payer: Cash Price |
$15,447.16
|
| Rate for Payer: Cash Price |
$15,447.16
|
| Rate for Payer: Cigna Commercial |
$25,642.28
|
| Rate for Payer: First Health Commercial |
$29,349.59
|
| Rate for Payer: Humana Commercial |
$26,260.16
|
| Rate for Payer: Humana KY Medicaid |
$10,624.55
|
| Rate for Payer: Humana Medicare Advantage |
$58.56
|
| Rate for Payer: Kentucky WC Medicaid |
$10,732.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,333.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,800.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,837.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,186.99
|
| Rate for Payer: Ohio Health Group HMO |
$23,170.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,715.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,878.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,317.07
|
| Rate for Payer: PHCS Commercial |
$29,658.54
|
| Rate for Payer: United Healthcare All Payer |
$27,186.99
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE
|
Facility
|
OP
|
$1,231.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
34000032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$423.34 |
| Max. Negotiated Rate |
$1,181.76 |
| Rate for Payer: Aetna Commercial |
$947.87
|
| Rate for Payer: Anthem Medicaid |
$423.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$960.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$615.50
|
| Rate for Payer: Cash Price |
$615.50
|
| Rate for Payer: Cigna Commercial |
$1,021.73
|
| Rate for Payer: First Health Commercial |
$1,169.45
|
| Rate for Payer: Humana Commercial |
$1,046.35
|
| Rate for Payer: Humana KY Medicaid |
$423.34
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$427.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,009.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$908.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$431.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,083.28
|
| Rate for Payer: Ohio Health Group HMO |
$923.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$849.39
|
| Rate for Payer: PHCS Commercial |
$1,181.76
|
| Rate for Payer: United Healthcare All Payer |
$1,083.28
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE
|
Professional
|
Both
|
$1,231.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
34000032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$78.41 |
| Max. Negotiated Rate |
$738.60 |
| Rate for Payer: Aetna Commercial |
$524.86
|
| Rate for Payer: Ambetter Exchange |
$297.36
|
| Rate for Payer: Anthem Medicaid |
$169.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$297.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$297.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$356.83
|
| Rate for Payer: Cash Price |
$615.50
|
| Rate for Payer: Cash Price |
$615.50
|
| Rate for Payer: Cigna Commercial |
$410.70
|
| Rate for Payer: Healthspan PPO |
$524.59
|
| Rate for Payer: Humana Medicaid |
$169.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$297.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$297.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.91
|
| Rate for Payer: Molina Healthcare Passport |
$169.52
|
| Rate for Payer: Multiplan PHCS |
$738.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$386.57
|
| Rate for Payer: UHCCP Medicaid |
$430.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$297.36
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE
|
Facility
|
IP
|
$1,231.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
34000032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$369.30 |
| Max. Negotiated Rate |
$1,181.76 |
| Rate for Payer: Aetna Commercial |
$947.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$960.18
|
| Rate for Payer: Cash Price |
$615.50
|
| Rate for Payer: Cigna Commercial |
$1,021.73
|
| Rate for Payer: First Health Commercial |
$1,169.45
|
| Rate for Payer: Humana Commercial |
$1,046.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,009.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$908.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$369.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,083.28
|
| Rate for Payer: Ohio Health Group HMO |
$923.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$849.39
|
| Rate for Payer: PHCS Commercial |
$1,181.76
|
| Rate for Payer: United Healthcare All Payer |
$1,083.28
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE(P
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
340P0032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$524.86 |
| Rate for Payer: Aetna Commercial |
$524.86
|
| Rate for Payer: Ambetter Exchange |
$297.36
|
| Rate for Payer: Anthem Medicaid |
$169.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$297.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$297.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$356.83
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$410.70
|
| Rate for Payer: Healthspan PPO |
$524.59
|
| Rate for Payer: Humana Medicaid |
$169.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$297.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$297.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.91
|
| Rate for Payer: Molina Healthcare Passport |
$169.52
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$386.57
|
| Rate for Payer: UHCCP Medicaid |
$31.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$297.36
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE(T
|
Facility
|
OP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
340T0032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$392.39 |
| Max. Negotiated Rate |
$1,095.36 |
| Rate for Payer: Aetna Commercial |
$878.57
|
| Rate for Payer: Anthem Medicaid |
$392.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cigna Commercial |
$947.03
|
| Rate for Payer: First Health Commercial |
$1,083.95
|
| Rate for Payer: Humana Commercial |
$969.85
|
| Rate for Payer: Humana KY Medicaid |
$392.39
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$396.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$935.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$842.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$400.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,004.08
|
| Rate for Payer: Ohio Health Group HMO |
$855.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$992.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$787.29
|
| Rate for Payer: PHCS Commercial |
$1,095.36
|
| Rate for Payer: United Healthcare All Payer |
$1,004.08
|
|
|
K FLOW/FUNCT IMAGE MULTIPLE(T
|
Facility
|
IP
|
$1,141.00
|
|
|
Service Code
|
HCPCS 78709
|
| Hospital Charge Code |
340T0032
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$342.30 |
| Max. Negotiated Rate |
$1,095.36 |
| Rate for Payer: Aetna Commercial |
$878.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.98
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cigna Commercial |
$947.03
|
| Rate for Payer: First Health Commercial |
$1,083.95
|
| Rate for Payer: Humana Commercial |
$969.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$935.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$842.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,004.08
|
| Rate for Payer: Ohio Health Group HMO |
$855.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$992.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$787.29
|
| Rate for Payer: PHCS Commercial |
$1,095.36
|
| Rate for Payer: United Healthcare All Payer |
$1,004.08
|
|
|
K FLOW/FUNCT IMAGE W/DRUG
|
Facility
|
IP
|
$885.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
34000031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$265.50 |
| Max. Negotiated Rate |
$849.60 |
| Rate for Payer: Aetna Commercial |
$681.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$690.30
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$734.55
|
| Rate for Payer: First Health Commercial |
$840.75
|
| Rate for Payer: Humana Commercial |
$752.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$725.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$653.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$778.80
|
| Rate for Payer: Ohio Health Group HMO |
$663.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$769.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$610.65
|
| Rate for Payer: PHCS Commercial |
$849.60
|
| Rate for Payer: United Healthcare All Payer |
$778.80
|
|
|
K FLOW/FUNCT IMAGE W/DRUG
|
Facility
|
OP
|
$885.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
34000031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$304.35 |
| Max. Negotiated Rate |
$849.60 |
| Rate for Payer: Aetna Commercial |
$681.45
|
| Rate for Payer: Anthem Medicaid |
$304.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$690.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$734.55
|
| Rate for Payer: First Health Commercial |
$840.75
|
| Rate for Payer: Humana Commercial |
$752.25
|
| Rate for Payer: Humana KY Medicaid |
$304.35
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$307.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$725.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$653.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$310.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$778.80
|
| Rate for Payer: Ohio Health Group HMO |
$663.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$769.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$610.65
|
| Rate for Payer: PHCS Commercial |
$849.60
|
| Rate for Payer: United Healthcare All Payer |
$778.80
|
|
|
K FLOW/FUNCT IMAGE W/DRUG
|
Professional
|
Both
|
$885.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
34000031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$67.16 |
| Max. Negotiated Rate |
$531.00 |
| Rate for Payer: Aetna Commercial |
$295.83
|
| Rate for Payer: Ambetter Exchange |
$159.13
|
| Rate for Payer: Anthem Medicaid |
$163.76
|
| Rate for Payer: Buckeye Individual/Medicaid |
$159.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$159.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.96
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cash Price |
$442.50
|
| Rate for Payer: Cigna Commercial |
$325.61
|
| Rate for Payer: Healthspan PPO |
$295.68
|
| Rate for Payer: Humana Medicaid |
$163.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$159.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$167.04
|
| Rate for Payer: Molina Healthcare Passport |
$163.76
|
| Rate for Payer: Multiplan PHCS |
$531.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$206.87
|
| Rate for Payer: UHCCP Medicaid |
$309.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$165.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$159.13
|
|
|
K FLOW/FUNCT IMAGE W/DRUG(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
340P0031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$325.61 |
| Rate for Payer: Aetna Commercial |
$295.83
|
| Rate for Payer: Ambetter Exchange |
$159.13
|
| Rate for Payer: Anthem Medicaid |
$163.76
|
| Rate for Payer: Buckeye Individual/Medicaid |
$159.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$159.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.96
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$325.61
|
| Rate for Payer: Healthspan PPO |
$295.68
|
| Rate for Payer: Humana Medicaid |
$163.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$159.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$167.04
|
| Rate for Payer: Molina Healthcare Passport |
$163.76
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$206.87
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$165.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$159.13
|
|
|
K FLOW/FUNCT IMAGE W/DRUG(T
|
Facility
|
IP
|
$710.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
340T0031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$213.00 |
| Max. Negotiated Rate |
$681.60 |
| Rate for Payer: Aetna Commercial |
$546.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.80
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cigna Commercial |
$589.30
|
| Rate for Payer: First Health Commercial |
$674.50
|
| Rate for Payer: Humana Commercial |
$603.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$582.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.80
|
| Rate for Payer: Ohio Health Group HMO |
$532.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$568.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$617.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$489.90
|
| Rate for Payer: PHCS Commercial |
$681.60
|
| Rate for Payer: United Healthcare All Payer |
$624.80
|
|
|
K FLOW/FUNCT IMAGE W/DRUG(T
|
Facility
|
OP
|
$710.00
|
|
|
Service Code
|
HCPCS 78708
|
| Hospital Charge Code |
340T0031
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$244.17 |
| Max. Negotiated Rate |
$696.29 |
| Rate for Payer: Aetna Commercial |
$546.70
|
| Rate for Payer: Anthem Medicaid |
$244.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cigna Commercial |
$589.30
|
| Rate for Payer: First Health Commercial |
$674.50
|
| Rate for Payer: Humana Commercial |
$603.50
|
| Rate for Payer: Humana KY Medicaid |
$244.17
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$246.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$582.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$249.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.80
|
| Rate for Payer: Ohio Health Group HMO |
$532.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$568.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$617.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$489.90
|
| Rate for Payer: PHCS Commercial |
$681.60
|
| Rate for Payer: United Healthcare All Payer |
$624.80
|
|
|
K FLOW/FUNCT IMAGE W/O DRUG
|
Facility
|
OP
|
$1,306.00
|
|
|
Service Code
|
HCPCS 78707
|
| Hospital Charge Code |
34000030
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$449.13 |
| Max. Negotiated Rate |
$1,253.76 |
| Rate for Payer: Aetna Commercial |
$1,005.62
|
| Rate for Payer: Anthem Medicaid |
$449.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,018.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$1,083.98
|
| Rate for Payer: First Health Commercial |
$1,240.70
|
| Rate for Payer: Humana Commercial |
$1,110.10
|
| Rate for Payer: Humana KY Medicaid |
$449.13
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$453.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,070.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$963.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$458.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,149.28
|
| Rate for Payer: Ohio Health Group HMO |
$979.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,044.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$901.14
|
| Rate for Payer: PHCS Commercial |
$1,253.76
|
| Rate for Payer: United Healthcare All Payer |
$1,149.28
|
|
