|
LOKELMA 5GM POWDER PACKET
|
Facility
|
IP
|
$64.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$61.49 |
| Rate for Payer: Aetna Commercial |
$49.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.96
|
| Rate for Payer: Cash Price |
$32.02
|
| Rate for Payer: Cigna Commercial |
$53.16
|
| Rate for Payer: First Health Commercial |
$60.85
|
| Rate for Payer: Humana Commercial |
$54.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.36
|
| Rate for Payer: Ohio Health Group HMO |
$48.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.86
|
| Rate for Payer: PHCS Commercial |
$61.49
|
| Rate for Payer: United Healthcare All Payer |
$56.36
|
|
|
LOKELMA 5GM POWDER PACKET
|
Facility
|
OP
|
$64.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25003183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$61.49 |
| Rate for Payer: Aetna Commercial |
$49.32
|
| Rate for Payer: Anthem Medicaid |
$22.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.96
|
| Rate for Payer: Cash Price |
$32.02
|
| Rate for Payer: Cigna Commercial |
$53.16
|
| Rate for Payer: First Health Commercial |
$60.85
|
| Rate for Payer: Humana Commercial |
$54.44
|
| Rate for Payer: Humana KY Medicaid |
$22.03
|
| Rate for Payer: Kentucky WC Medicaid |
$22.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$52.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$56.36
|
| Rate for Payer: Ohio Health Group HMO |
$48.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.86
|
| Rate for Payer: PHCS Commercial |
$61.49
|
| Rate for Payer: United Healthcare All Payer |
$56.36
|
|
|
LONGEVITY LINER NEUT 54JJ 36
|
Facility
|
IP
|
$7,307.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$950.01 |
| Max. Negotiated Rate |
$7,015.44 |
| Rate for Payer: Aetna Commercial |
$5,626.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,700.04
|
| Rate for Payer: Cash Price |
$3,653.88
|
| Rate for Payer: Cigna Commercial |
$6,065.43
|
| Rate for Payer: First Health Commercial |
$6,942.36
|
| Rate for Payer: Humana Commercial |
$6,211.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,992.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,393.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,192.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,430.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,480.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,461.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$950.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,265.40
|
| Rate for Payer: PHCS Commercial |
$7,015.44
|
| Rate for Payer: United Healthcare All Payer |
$6,430.82
|
|
|
LONGEVITY LINER NEUT 54JJ 36
|
Facility
|
OP
|
$7,307.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$950.01 |
| Max. Negotiated Rate |
$7,015.44 |
| Rate for Payer: Aetna Commercial |
$5,626.97
|
| Rate for Payer: Anthem Medicaid |
$2,513.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,700.04
|
| Rate for Payer: Cash Price |
$3,653.88
|
| Rate for Payer: Cigna Commercial |
$6,065.43
|
| Rate for Payer: First Health Commercial |
$6,942.36
|
| Rate for Payer: Humana Commercial |
$6,211.59
|
| Rate for Payer: Humana KY Medicaid |
$2,513.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,992.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,393.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,192.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,430.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,480.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,461.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$950.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,265.40
|
| Rate for Payer: PHCS Commercial |
$7,015.44
|
| Rate for Payer: United Healthcare All Payer |
$6,430.82
|
|
|
LONG OPTION 100CM FILTER
|
Facility
|
IP
|
$8,457.50
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,099.48 |
| Max. Negotiated Rate |
$8,119.20 |
| Rate for Payer: Aetna Commercial |
$6,512.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,596.85
|
| Rate for Payer: Cash Price |
$4,228.75
|
| Rate for Payer: Cigna Commercial |
$7,019.72
|
| Rate for Payer: First Health Commercial |
$8,034.62
|
| Rate for Payer: Humana Commercial |
$7,188.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,935.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,241.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,537.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,442.60
|
| Rate for Payer: Ohio Health Group HMO |
$6,343.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,691.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,099.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,621.82
|
| Rate for Payer: PHCS Commercial |
$8,119.20
|
| Rate for Payer: United Healthcare All Payer |
$7,442.60
|
|
|
LONG OPTION 100CM FILTER
|
Facility
|
OP
|
$8,457.50
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,099.48 |
| Max. Negotiated Rate |
$8,119.20 |
| Rate for Payer: Aetna Commercial |
$6,512.28
|
| Rate for Payer: Anthem Medicaid |
$2,908.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,596.85
|
| Rate for Payer: Cash Price |
$4,228.75
|
| Rate for Payer: Cigna Commercial |
$7,019.72
|
| Rate for Payer: First Health Commercial |
$8,034.62
|
| Rate for Payer: Humana Commercial |
$7,188.88
|
| Rate for Payer: Humana KY Medicaid |
$2,908.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,938.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,935.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,241.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,537.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,966.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,442.60
|
| Rate for Payer: Ohio Health Group HMO |
$6,343.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,691.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,099.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,621.82
|
| Rate for Payer: PHCS Commercial |
$8,119.20
|
| Rate for Payer: United Healthcare All Payer |
$7,442.60
|
|
|
LONITEN (MINOXIDIL) 10MG/1TAB
|
Facility
|
IP
|
$4.84
|
|
|
Service Code
|
NDC 68084020501
|
| Hospital Charge Code |
25000903
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.02
|
| Rate for Payer: First Health Commercial |
$4.60
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.26
|
| Rate for Payer: Ohio Health Group HMO |
$3.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Payer |
$4.26
|
|
|
LONITEN (MINOXIDIL) 10MG/1TAB
|
Facility
|
OP
|
$4.84
|
|
|
Service Code
|
NDC 68084020501
|
| Hospital Charge Code |
25000903
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.02
|
| Rate for Payer: First Health Commercial |
$4.60
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.26
|
| Rate for Payer: Ohio Health Group HMO |
$3.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Payer |
$4.26
|
|
|
LONITEN (MINOXIDIL) 2.5MG/1TAB
|
Facility
|
IP
|
$4.72
|
|
|
Service Code
|
NDC 68084020401
|
| Hospital Charge Code |
25000904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
LONITEN (MINOXIDIL) 2.5MG/1TAB
|
Facility
|
OP
|
$4.72
|
|
|
Service Code
|
NDC 68084020401
|
| Hospital Charge Code |
25000904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
LOOP N TAK KNOTLESS KIT
|
Facility
|
OP
|
$5,360.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$696.86 |
| Max. Negotiated Rate |
$5,146.08 |
| Rate for Payer: Aetna Commercial |
$4,127.58
|
| Rate for Payer: Anthem Medicaid |
$1,843.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,181.19
|
| Rate for Payer: Cash Price |
$2,680.25
|
| Rate for Payer: Cigna Commercial |
$4,449.22
|
| Rate for Payer: First Health Commercial |
$5,092.48
|
| Rate for Payer: Humana Commercial |
$4,556.42
|
| Rate for Payer: Humana KY Medicaid |
$1,843.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,862.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,395.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,956.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,608.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,880.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,717.24
|
| Rate for Payer: Ohio Health Group HMO |
$4,020.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,072.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,661.76
|
| Rate for Payer: PHCS Commercial |
$5,146.08
|
| Rate for Payer: United Healthcare All Payer |
$4,717.24
|
|
|
LOOP N TAK KNOTLESS KIT
|
Facility
|
IP
|
$5,360.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$696.86 |
| Max. Negotiated Rate |
$5,146.08 |
| Rate for Payer: Aetna Commercial |
$4,127.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,181.19
|
| Rate for Payer: Cash Price |
$2,680.25
|
| Rate for Payer: Cigna Commercial |
$4,449.22
|
| Rate for Payer: First Health Commercial |
$5,092.48
|
| Rate for Payer: Humana Commercial |
$4,556.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,395.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,956.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,608.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,717.24
|
| Rate for Payer: Ohio Health Group HMO |
$4,020.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,072.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,661.76
|
| Rate for Payer: PHCS Commercial |
$5,146.08
|
| Rate for Payer: United Healthcare All Payer |
$4,717.24
|
|
|
LOOP ORGAN DONATION
|
Facility
|
IP
|
$4,260.00
|
|
| Hospital Charge Code |
36001287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$553.80 |
| Max. Negotiated Rate |
$4,089.60 |
| Rate for Payer: Aetna Commercial |
$3,280.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,322.80
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cigna Commercial |
$3,535.80
|
| Rate for Payer: First Health Commercial |
$4,047.00
|
| Rate for Payer: Humana Commercial |
$3,621.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,493.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,143.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,278.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,748.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,195.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,320.60
|
| Rate for Payer: PHCS Commercial |
$4,089.60
|
| Rate for Payer: United Healthcare All Payer |
$3,748.80
|
|
|
LOOP ORGAN DONATION
|
Facility
|
OP
|
$4,260.00
|
|
| Hospital Charge Code |
36001287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$553.80 |
| Max. Negotiated Rate |
$4,089.60 |
| Rate for Payer: Aetna Commercial |
$3,280.20
|
| Rate for Payer: Anthem Medicaid |
$1,465.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,322.80
|
| Rate for Payer: Cash Price |
$2,130.00
|
| Rate for Payer: Cigna Commercial |
$3,535.80
|
| Rate for Payer: First Health Commercial |
$4,047.00
|
| Rate for Payer: Humana Commercial |
$3,621.00
|
| Rate for Payer: Humana KY Medicaid |
$1,465.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,479.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,493.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,143.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,278.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,494.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,748.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,195.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,320.60
|
| Rate for Payer: PHCS Commercial |
$4,089.60
|
| Rate for Payer: United Healthcare All Payer |
$3,748.80
|
|
|
LOOP RECORDER INSERTABLE
|
Facility
|
OP
|
$16,062.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,088.06 |
| Max. Negotiated Rate |
$15,419.52 |
| Rate for Payer: Aetna Commercial |
$12,367.74
|
| Rate for Payer: Anthem Medicaid |
$5,523.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,528.36
|
| Rate for Payer: Cash Price |
$8,031.00
|
| Rate for Payer: Cigna Commercial |
$13,331.46
|
| Rate for Payer: First Health Commercial |
$15,258.90
|
| Rate for Payer: Humana Commercial |
$13,652.70
|
| Rate for Payer: Humana KY Medicaid |
$5,523.72
|
| Rate for Payer: Kentucky WC Medicaid |
$5,579.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,170.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,853.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,818.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,634.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,134.56
|
| Rate for Payer: Ohio Health Group HMO |
$12,046.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,212.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,088.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,979.22
|
| Rate for Payer: PHCS Commercial |
$15,419.52
|
| Rate for Payer: United Healthcare All Payer |
$14,134.56
|
|
|
LOOP RECORDER INSERTABLE
|
Facility
|
IP
|
$16,062.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,088.06 |
| Max. Negotiated Rate |
$15,419.52 |
| Rate for Payer: Aetna Commercial |
$12,367.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,528.36
|
| Rate for Payer: Cash Price |
$8,031.00
|
| Rate for Payer: Cigna Commercial |
$13,331.46
|
| Rate for Payer: First Health Commercial |
$15,258.90
|
| Rate for Payer: Humana Commercial |
$13,652.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,170.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,853.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,818.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,134.56
|
| Rate for Payer: Ohio Health Group HMO |
$12,046.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,212.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,088.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,979.22
|
| Rate for Payer: PHCS Commercial |
$15,419.52
|
| Rate for Payer: United Healthcare All Payer |
$14,134.56
|
|
|
LOOP RECORDER REVEAL LINQ
|
Facility
|
IP
|
$21,225.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
|
|
LOOP RECORDER REVEAL LINQ
|
Facility
|
OP
|
$21,225.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Anthem Medicaid |
$7,299.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Humana KY Medicaid |
$7,299.28
|
| Rate for Payer: Kentucky WC Medicaid |
$7,373.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,445.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
|
|
LOOP RECORDER REVEAL LINQ II
|
Facility
|
IP
|
$21,225.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
|
|
LOOP RECORDER REVEAL LINQ II
|
Facility
|
OP
|
$21,225.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,759.25 |
| Max. Negotiated Rate |
$20,376.00 |
| Rate for Payer: Aetna Commercial |
$16,343.25
|
| Rate for Payer: Anthem Medicaid |
$7,299.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,555.50
|
| Rate for Payer: Cash Price |
$10,612.50
|
| Rate for Payer: Cigna Commercial |
$17,616.75
|
| Rate for Payer: First Health Commercial |
$20,163.75
|
| Rate for Payer: Humana Commercial |
$18,041.25
|
| Rate for Payer: Humana KY Medicaid |
$7,299.28
|
| Rate for Payer: Kentucky WC Medicaid |
$7,373.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,404.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,664.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,367.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,445.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,678.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,245.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,759.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,579.75
|
| Rate for Payer: PHCS Commercial |
$20,376.00
|
| Rate for Payer: United Healthcare All Payer |
$18,678.00
|
|
|
LOOP RECORDER REVEAL XT 9529
|
Facility
|
OP
|
$18,042.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,345.46 |
| Max. Negotiated Rate |
$17,320.32 |
| Rate for Payer: Aetna Commercial |
$13,892.34
|
| Rate for Payer: Anthem Medicaid |
$6,204.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,072.76
|
| Rate for Payer: Cash Price |
$9,021.00
|
| Rate for Payer: Cigna Commercial |
$14,974.86
|
| Rate for Payer: First Health Commercial |
$17,139.90
|
| Rate for Payer: Humana Commercial |
$15,335.70
|
| Rate for Payer: Humana KY Medicaid |
$6,204.64
|
| Rate for Payer: Kentucky WC Medicaid |
$6,267.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,794.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,315.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,412.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,329.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,876.96
|
| Rate for Payer: Ohio Health Group HMO |
$13,531.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,608.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,345.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,593.02
|
| Rate for Payer: PHCS Commercial |
$17,320.32
|
| Rate for Payer: United Healthcare All Payer |
$15,876.96
|
|
|
LOOP RECORDER REVEAL XT 9529
|
Facility
|
IP
|
$18,042.00
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,345.46 |
| Max. Negotiated Rate |
$17,320.32 |
| Rate for Payer: Aetna Commercial |
$13,892.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,072.76
|
| Rate for Payer: Cash Price |
$9,021.00
|
| Rate for Payer: Cigna Commercial |
$14,974.86
|
| Rate for Payer: First Health Commercial |
$17,139.90
|
| Rate for Payer: Humana Commercial |
$15,335.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,794.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,315.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,412.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,876.96
|
| Rate for Payer: Ohio Health Group HMO |
$13,531.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,608.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,345.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,593.02
|
| Rate for Payer: PHCS Commercial |
$17,320.32
|
| Rate for Payer: United Healthcare All Payer |
$15,876.96
|
|
|
LOPID (GEMFIBROZIL) 600MG/1TAB
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 60687022401
|
| Hospital Charge Code |
25000905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
LOPID (GEMFIBROZIL) 600MG/1TAB
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 60687022401
|
| Hospital Charge Code |
25000905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
LOPRESSOR (METOPROLO 25MG/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 62584026501
|
| Hospital Charge Code |
25000906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
