|
LIPO (TRUNK)
|
Professional
|
Both
|
$800.00
|
|
| Hospital Charge Code |
22200051
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
|
|
LIPO TRUNK
|
Facility
|
IP
|
$7,035.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
76100229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$914.66 |
| Max. Negotiated Rate |
$6,754.41 |
| Rate for Payer: Aetna Commercial |
$5,417.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,487.96
|
| Rate for Payer: Cash Price |
$3,517.92
|
| Rate for Payer: Cigna Commercial |
$5,839.75
|
| Rate for Payer: First Health Commercial |
$6,684.05
|
| Rate for Payer: Humana Commercial |
$5,980.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,769.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,192.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,110.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,191.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,276.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,407.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$914.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.11
|
| Rate for Payer: PHCS Commercial |
$6,754.41
|
| Rate for Payer: United Healthcare All Payer |
$6,191.54
|
|
|
LIPO TRUNK
|
Professional
|
Both
|
$7,035.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
76100229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$7,035.84 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,035.84
|
| Rate for Payer: Cash Price |
$3,517.92
|
| Rate for Payer: Cash Price |
$3,517.92
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$307.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$4,221.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,925.09
|
| Rate for Payer: UHCCP Medicaid |
$2,462.54
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
LIPO TRUNK
|
Facility
|
OP
|
$7,035.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
76100229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$914.66 |
| Max. Negotiated Rate |
$6,754.41 |
| Rate for Payer: Aetna Commercial |
$5,417.60
|
| Rate for Payer: Anthem Medicaid |
$2,419.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,487.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,517.92
|
| Rate for Payer: Cash Price |
$3,517.92
|
| Rate for Payer: Cigna Commercial |
$5,839.75
|
| Rate for Payer: First Health Commercial |
$6,684.05
|
| Rate for Payer: Humana Commercial |
$5,980.46
|
| Rate for Payer: Humana KY Medicaid |
$2,419.63
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,444.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,769.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,192.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,468.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,191.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,276.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,407.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$914.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.11
|
| Rate for Payer: PHCS Commercial |
$6,754.41
|
| Rate for Payer: United Healthcare All Payer |
$6,191.54
|
|
|
LIPO (TRUNK) -80
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200379
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
LIPO TRUNK(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
761P0229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$144.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$307.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.75
|
| Rate for Payer: Molina Healthcare Passport |
$144.85
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.30
|
|
|
LIPO TRUNK(T
|
Facility
|
IP
|
$5,435.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
761T0229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$706.66 |
| Max. Negotiated Rate |
$5,218.41 |
| Rate for Payer: Aetna Commercial |
$4,185.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,239.96
|
| Rate for Payer: Cash Price |
$2,717.92
|
| Rate for Payer: Cigna Commercial |
$4,511.75
|
| Rate for Payer: First Health Commercial |
$5,164.05
|
| Rate for Payer: Humana Commercial |
$4,620.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,457.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,011.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,630.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,783.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,076.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.11
|
| Rate for Payer: PHCS Commercial |
$5,218.41
|
| Rate for Payer: United Healthcare All Payer |
$4,783.54
|
|
|
LIPO TRUNK(T
|
Facility
|
OP
|
$5,435.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
761T0229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$706.66 |
| Max. Negotiated Rate |
$5,218.41 |
| Rate for Payer: Aetna Commercial |
$4,185.60
|
| Rate for Payer: Anthem Medicaid |
$1,869.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,239.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,717.92
|
| Rate for Payer: Cash Price |
$2,717.92
|
| Rate for Payer: Cigna Commercial |
$4,511.75
|
| Rate for Payer: First Health Commercial |
$5,164.05
|
| Rate for Payer: Humana Commercial |
$4,620.46
|
| Rate for Payer: Humana KY Medicaid |
$1,869.39
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,457.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,011.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,906.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,783.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,076.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.11
|
| Rate for Payer: PHCS Commercial |
$5,218.41
|
| Rate for Payer: United Healthcare All Payer |
$4,783.54
|
|
|
LISTERIA SP TUF GENE
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001300
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
LISTERIA SP TUF GENE
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001300
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna Commercial |
$56.44
|
| Rate for Payer: First Health Commercial |
$64.60
|
| Rate for Payer: Humana Commercial |
$57.80
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.84
|
| Rate for Payer: Ohio Health Group HMO |
$51.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.08
|
| Rate for Payer: PHCS Commercial |
$65.28
|
| Rate for Payer: United Healthcare All Payer |
$59.84
|
|
|
LITHIUM
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Aetna Commercial |
$73.92
|
| Rate for Payer: Anthem Medicaid |
$6.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.61
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$79.68
|
| Rate for Payer: First Health Commercial |
$91.20
|
| Rate for Payer: Humana Commercial |
$81.60
|
| Rate for Payer: Humana KY Medicaid |
$6.61
|
| Rate for Payer: Humana Medicare Advantage |
$6.61
|
| Rate for Payer: Kentucky WC Medicaid |
$6.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.48
|
| Rate for Payer: Ohio Health Group HMO |
$72.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.76
|
| Rate for Payer: PHCS Commercial |
$92.16
|
| Rate for Payer: United Healthcare All Payer |
$84.48
|
|
|
LITHIUM
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Aetna Commercial |
$73.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.09
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$79.68
|
| Rate for Payer: First Health Commercial |
$91.20
|
| Rate for Payer: Humana Commercial |
$81.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.48
|
| Rate for Payer: Ohio Health Group HMO |
$72.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.76
|
| Rate for Payer: PHCS Commercial |
$92.16
|
| Rate for Payer: United Healthcare All Payer |
$84.48
|
|
|
LITHIUM
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$12.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$5.78
|
| Rate for Payer: Healthspan PPO |
$6.93
|
| Rate for Payer: Multiplan PHCS |
$57.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$67.20
|
| Rate for Payer: UHCCP Medicaid |
$33.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.97
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 54852625
|
| Hospital Charge Code |
25000884
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 54852625
|
| Hospital Charge Code |
25000884
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
LITHOBID (LITHIUM) 300MG/1TAB
|
Facility
|
IP
|
$29.75
|
|
|
Service Code
|
NDC 62559028001
|
| Hospital Charge Code |
25000887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$28.56 |
| Rate for Payer: Humana Commercial |
$25.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.18
|
| Rate for Payer: Ohio Health Group HMO |
$22.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.22
|
| Rate for Payer: PHCS Commercial |
$28.56
|
| Rate for Payer: United Healthcare All Payer |
$26.18
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.20
|
| Rate for Payer: Cash Price |
$14.88
|
| Rate for Payer: Cigna Commercial |
$24.69
|
| Rate for Payer: First Health Commercial |
$28.26
|
|
|
LITHOBID (LITHIUM) 300MG/1TAB
|
Facility
|
OP
|
$29.75
|
|
|
Service Code
|
NDC 62559028001
|
| Hospital Charge Code |
25000887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.87 |
| Max. Negotiated Rate |
$28.56 |
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Anthem Medicaid |
$10.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.20
|
| Rate for Payer: Cash Price |
$14.88
|
| Rate for Payer: Cigna Commercial |
$24.69
|
| Rate for Payer: First Health Commercial |
$28.26
|
| Rate for Payer: Humana Commercial |
$25.29
|
| Rate for Payer: Humana KY Medicaid |
$10.23
|
| Rate for Payer: Kentucky WC Medicaid |
$10.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.18
|
| Rate for Payer: Ohio Health Group HMO |
$22.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.22
|
| Rate for Payer: PHCS Commercial |
$28.56
|
| Rate for Payer: United Healthcare All Payer |
$26.18
|
|
|
LITHOBID (LITHIUM C 300MG/1CAP
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 54852725
|
| Hospital Charge Code |
25000886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
LITHOBID (LITHIUM C 300MG/1CAP
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 54852725
|
| Hospital Charge Code |
25000886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)
|
Facility
|
OP
|
$4,220.54
|
|
|
Service Code
|
CPT 52318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,014.67 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)
|
Facility
|
OP
|
$4,220.54
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,014.67 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
|
|
LITHOTRIPSY, SHOCK WAVE
|
Professional
|
Both
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
76102053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$348.52 |
| Max. Negotiated Rate |
$4,900.00 |
| Rate for Payer: Aetna Commercial |
$915.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$348.52
|
| Rate for Payer: Anthem Medicaid |
$577.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,900.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$805.13
|
| Rate for Payer: Healthspan PPO |
$1,165.88
|
| Rate for Payer: Humana Medicaid |
$577.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$768.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.56
|
| Rate for Payer: Molina Healthcare Passport |
$577.02
|
| Rate for Payer: Multiplan PHCS |
$2,940.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,430.00
|
| Rate for Payer: UHCCP Medicaid |
$365.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.79
|
|
|
LITHOTRIPSY, SHOCK WAVE
|
Facility
|
OP
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
76102053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$637.00 |
| Max. Negotiated Rate |
$4,704.00 |
| Rate for Payer: Aetna Commercial |
$3,773.00
|
| Rate for Payer: Anthem Medicaid |
$1,685.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$4,067.00
|
| Rate for Payer: First Health Commercial |
$4,655.00
|
| Rate for Payer: Humana Commercial |
$4,165.00
|
| Rate for Payer: Humana KY Medicaid |
$1,685.11
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,702.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,018.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,616.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,718.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,312.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$980.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,519.00
|
| Rate for Payer: PHCS Commercial |
$4,704.00
|
| Rate for Payer: United Healthcare All Payer |
$4,312.00
|
|
|
LITHOTRIPSY, SHOCK WAVE
|
Facility
|
IP
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
76102053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$637.00 |
| Max. Negotiated Rate |
$4,704.00 |
| Rate for Payer: Aetna Commercial |
$3,773.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$4,067.00
|
| Rate for Payer: First Health Commercial |
$4,655.00
|
| Rate for Payer: Humana Commercial |
$4,165.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,018.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,616.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,312.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$980.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,519.00
|
| Rate for Payer: PHCS Commercial |
$4,704.00
|
| Rate for Payer: United Healthcare All Payer |
$4,312.00
|
|
|
LITHOTRIPSY, SHOCK WAVE(P
|
Professional
|
Both
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
761P2053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$348.52 |
| Max. Negotiated Rate |
$4,900.00 |
| Rate for Payer: Aetna Commercial |
$915.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$348.52
|
| Rate for Payer: Anthem Medicaid |
$577.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,900.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cash Price |
$2,450.00
|
| Rate for Payer: Cigna Commercial |
$805.13
|
| Rate for Payer: Healthspan PPO |
$1,165.88
|
| Rate for Payer: Humana Medicaid |
$577.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$768.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.56
|
| Rate for Payer: Molina Healthcare Passport |
$577.02
|
| Rate for Payer: Multiplan PHCS |
$2,940.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,430.00
|
| Rate for Payer: UHCCP Medicaid |
$365.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.79
|
|
