|
LUNESTA (ESZOPICLONE) 1MG TAB
|
Facility
|
OP
|
$60.16
|
|
|
Service Code
|
NDC 65862096730
|
| Hospital Charge Code |
25000925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.75 |
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Humana KY Medicaid |
$20.69
|
| Rate for Payer: Kentucky WC Medicaid |
$20.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.94
|
| Rate for Payer: Ohio Health Group HMO |
$45.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.75
|
| Rate for Payer: United Healthcare All Payer |
$52.94
|
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem Medicaid |
$20.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.93
|
| Rate for Payer: First Health Commercial |
$57.15
|
|
|
LUNESTA (ESZOPICLONE) 1MG TAB
|
Facility
|
IP
|
$60.16
|
|
|
Service Code
|
NDC 65862096730
|
| Hospital Charge Code |
25000925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.75 |
| Rate for Payer: Aetna Commercial |
$46.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.92
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cigna Commercial |
$49.93
|
| Rate for Payer: First Health Commercial |
$57.15
|
| Rate for Payer: Humana Commercial |
$51.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.94
|
| Rate for Payer: Ohio Health Group HMO |
$45.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.65
|
| Rate for Payer: PHCS Commercial |
$57.75
|
| Rate for Payer: United Healthcare All Payer |
$52.94
|
|
|
LUNESTA (ESZOPICLONE) 2MG TAB
|
Facility
|
IP
|
$60.50
|
|
|
Service Code
|
NDC 68462038301
|
| Hospital Charge Code |
25000926
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$58.08 |
| Rate for Payer: Aetna Commercial |
$46.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.19
|
| Rate for Payer: Cash Price |
$30.25
|
| Rate for Payer: Cigna Commercial |
$50.22
|
| Rate for Payer: First Health Commercial |
$57.48
|
| Rate for Payer: Humana Commercial |
$51.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.24
|
| Rate for Payer: Ohio Health Group HMO |
$45.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.76
|
| Rate for Payer: PHCS Commercial |
$58.08
|
| Rate for Payer: United Healthcare All Payer |
$53.24
|
|
|
LUNESTA (ESZOPICLONE) 2MG TAB
|
Facility
|
OP
|
$60.50
|
|
|
Service Code
|
NDC 68462038301
|
| Hospital Charge Code |
25000926
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$58.08 |
| Rate for Payer: Aetna Commercial |
$46.58
|
| Rate for Payer: Anthem Medicaid |
$20.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.19
|
| Rate for Payer: Cash Price |
$30.25
|
| Rate for Payer: Cigna Commercial |
$50.22
|
| Rate for Payer: First Health Commercial |
$57.48
|
| Rate for Payer: Humana Commercial |
$51.42
|
| Rate for Payer: Humana KY Medicaid |
$20.81
|
| Rate for Payer: Kentucky WC Medicaid |
$21.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.24
|
| Rate for Payer: Ohio Health Group HMO |
$45.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.76
|
| Rate for Payer: PHCS Commercial |
$58.08
|
| Rate for Payer: United Healthcare All Payer |
$53.24
|
|
|
LUNESTA (ESZOPICLONE) 3MG TAB
|
Facility
|
IP
|
$60.18
|
|
|
Service Code
|
NDC 65862096901
|
| Hospital Charge Code |
25000927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
LUNESTA (ESZOPICLONE) 3MG TAB
|
Facility
|
OP
|
$60.18
|
|
|
Service Code
|
NDC 65862096901
|
| Hospital Charge Code |
25000927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Humana KY Medicaid |
$20.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Professional
|
Both
|
$1,168.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$38.52 |
| Max. Negotiated Rate |
$1,168.00 |
| Rate for Payer: Anthem Medicaid |
$151.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,168.00
|
| Rate for Payer: Cash Price |
$584.00
|
| Rate for Payer: Cash Price |
$584.00
|
| Rate for Payer: Cigna Commercial |
$321.99
|
| Rate for Payer: Healthspan PPO |
$214.10
|
| Rate for Payer: Humana Medicaid |
$151.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.48
|
| Rate for Payer: Molina Healthcare Passport |
$151.45
|
| Rate for Payer: Multiplan PHCS |
$700.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$817.60
|
| Rate for Payer: UHCCP Medicaid |
$408.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.96
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Facility
|
IP
|
$1,168.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$151.84 |
| Max. Negotiated Rate |
$1,121.28 |
| Rate for Payer: Aetna Commercial |
$899.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$911.04
|
| Rate for Payer: Cash Price |
$584.00
|
| Rate for Payer: Cigna Commercial |
$969.44
|
| Rate for Payer: First Health Commercial |
$1,109.60
|
| Rate for Payer: Humana Commercial |
$992.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$957.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$350.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,027.84
|
| Rate for Payer: Ohio Health Group HMO |
$876.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.08
|
| Rate for Payer: PHCS Commercial |
$1,121.28
|
| Rate for Payer: United Healthcare All Payer |
$1,027.84
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Facility
|
OP
|
$1,168.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$151.84 |
| Max. Negotiated Rate |
$1,121.28 |
| Rate for Payer: Aetna Commercial |
$899.36
|
| Rate for Payer: Anthem Medicaid |
$401.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$911.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$584.00
|
| Rate for Payer: Cash Price |
$584.00
|
| Rate for Payer: Cigna Commercial |
$969.44
|
| Rate for Payer: First Health Commercial |
$1,109.60
|
| Rate for Payer: Humana Commercial |
$992.80
|
| Rate for Payer: Humana KY Medicaid |
$401.68
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$405.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$957.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$861.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$409.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,027.84
|
| Rate for Payer: Ohio Health Group HMO |
$876.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.08
|
| Rate for Payer: PHCS Commercial |
$1,121.28
|
| Rate for Payer: United Healthcare All Payer |
$1,027.84
|
|
|
LUNG QUANTITATIVE PERFUSION(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340P0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$38.52 |
| Max. Negotiated Rate |
$321.99 |
| Rate for Payer: Anthem Medicaid |
$151.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$321.99
|
| Rate for Payer: Healthspan PPO |
$214.10
|
| Rate for Payer: Humana Medicaid |
$151.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.48
|
| Rate for Payer: Molina Healthcare Passport |
$151.45
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.96
|
|
|
LUNG QUANTITATIVE PERFUSION(T
|
Facility
|
IP
|
$1,018.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340T0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$132.34 |
| Max. Negotiated Rate |
$977.28 |
| Rate for Payer: Aetna Commercial |
$783.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$794.04
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cigna Commercial |
$844.94
|
| Rate for Payer: First Health Commercial |
$967.10
|
| Rate for Payer: Humana Commercial |
$865.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$834.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$751.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$305.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$895.84
|
| Rate for Payer: Ohio Health Group HMO |
$763.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$315.58
|
| Rate for Payer: PHCS Commercial |
$977.28
|
| Rate for Payer: United Healthcare All Payer |
$895.84
|
|
|
LUNG QUANTITATIVE PERFUSION(T
|
Facility
|
OP
|
$1,018.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340T0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$132.34 |
| Max. Negotiated Rate |
$977.28 |
| Rate for Payer: Aetna Commercial |
$783.86
|
| Rate for Payer: Anthem Medicaid |
$350.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$794.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cigna Commercial |
$844.94
|
| Rate for Payer: First Health Commercial |
$967.10
|
| Rate for Payer: Humana Commercial |
$865.30
|
| Rate for Payer: Humana KY Medicaid |
$350.09
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$353.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$834.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$751.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$357.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$895.84
|
| Rate for Payer: Ohio Health Group HMO |
$763.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$315.58
|
| Rate for Payer: PHCS Commercial |
$977.28
|
| Rate for Payer: United Healthcare All Payer |
$895.84
|
|
|
LUNG TRANSPLANT
|
Facility
|
IP
|
$143,494.88
|
|
|
Service Code
|
MSDRG 007
|
| Min. Negotiated Rate |
$97,371.52 |
| Max. Negotiated Rate |
$143,494.88 |
| Rate for Payer: Anthem Medicaid |
$97,371.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$102,496.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$143,494.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$138,370.06
|
| Rate for Payer: Humana KY Medicaid |
$97,371.52
|
| Rate for Payer: Humana Medicare Advantage |
$102,496.34
|
| Rate for Payer: Kentucky WC Medicaid |
$98,345.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122,995.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$99,318.95
|
|
|
LUNG VENTILATION SCAN
|
Facility
|
OP
|
$1,056.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$137.28 |
| Max. Negotiated Rate |
$1,013.76 |
| Rate for Payer: Aetna Commercial |
$813.12
|
| Rate for Payer: Anthem Medicaid |
$363.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$823.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna Commercial |
$876.48
|
| Rate for Payer: First Health Commercial |
$1,003.20
|
| Rate for Payer: Humana Commercial |
$897.60
|
| Rate for Payer: Humana KY Medicaid |
$363.16
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$366.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$865.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$779.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$929.28
|
| Rate for Payer: Ohio Health Group HMO |
$792.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.36
|
| Rate for Payer: PHCS Commercial |
$1,013.76
|
| Rate for Payer: United Healthcare All Payer |
$929.28
|
|
|
LUNG VENTILATION SCAN
|
Professional
|
Both
|
$1,056.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Anthem Medicaid |
$133.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,056.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna Commercial |
$285.10
|
| Rate for Payer: Healthspan PPO |
$189.71
|
| Rate for Payer: Humana Medicaid |
$133.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.53
|
| Rate for Payer: Molina Healthcare Passport |
$133.85
|
| Rate for Payer: Multiplan PHCS |
$633.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$739.20
|
| Rate for Payer: UHCCP Medicaid |
$369.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.19
|
|
|
LUNG VENTILATION SCAN
|
Facility
|
IP
|
$1,056.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$137.28 |
| Max. Negotiated Rate |
$1,013.76 |
| Rate for Payer: Aetna Commercial |
$813.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$823.68
|
| Rate for Payer: Cash Price |
$528.00
|
| Rate for Payer: Cigna Commercial |
$876.48
|
| Rate for Payer: First Health Commercial |
$1,003.20
|
| Rate for Payer: Humana Commercial |
$897.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$865.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$779.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$316.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$929.28
|
| Rate for Payer: Ohio Health Group HMO |
$792.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$211.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$327.36
|
| Rate for Payer: PHCS Commercial |
$1,013.76
|
| Rate for Payer: United Healthcare All Payer |
$929.28
|
|
|
LUNG VENTILATION SCAN(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340P0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$285.10 |
| Rate for Payer: Anthem Medicaid |
$133.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$285.10
|
| Rate for Payer: Healthspan PPO |
$189.71
|
| Rate for Payer: Humana Medicaid |
$133.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.53
|
| Rate for Payer: Molina Healthcare Passport |
$133.85
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.19
|
|
|
LUNG VENTILATION SCAN(T
|
Facility
|
IP
|
$906.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340T0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$117.78 |
| Max. Negotiated Rate |
$869.76 |
| Rate for Payer: Aetna Commercial |
$697.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$706.68
|
| Rate for Payer: Cash Price |
$453.00
|
| Rate for Payer: Cigna Commercial |
$751.98
|
| Rate for Payer: First Health Commercial |
$860.70
|
| Rate for Payer: Humana Commercial |
$770.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$668.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$797.28
|
| Rate for Payer: Ohio Health Group HMO |
$679.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.86
|
| Rate for Payer: PHCS Commercial |
$869.76
|
| Rate for Payer: United Healthcare All Payer |
$797.28
|
|
|
LUNG VENTILATION SCAN(T
|
Facility
|
OP
|
$906.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340T0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$117.78 |
| Max. Negotiated Rate |
$869.76 |
| Rate for Payer: Aetna Commercial |
$697.62
|
| Rate for Payer: Anthem Medicaid |
$311.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$706.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$453.00
|
| Rate for Payer: Cash Price |
$453.00
|
| Rate for Payer: Cigna Commercial |
$751.98
|
| Rate for Payer: First Health Commercial |
$860.70
|
| Rate for Payer: Humana Commercial |
$770.10
|
| Rate for Payer: Humana KY Medicaid |
$311.57
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$314.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$668.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$317.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$797.28
|
| Rate for Payer: Ohio Health Group HMO |
$679.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.86
|
| Rate for Payer: PHCS Commercial |
$869.76
|
| Rate for Payer: United Healthcare All Payer |
$797.28
|
|
|
LUNG VOLUME REDUCTION
|
Facility
|
OP
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$461.50 |
| Max. Negotiated Rate |
$3,408.00 |
| Rate for Payer: Aetna Commercial |
$2,733.50
|
| Rate for Payer: Anthem Medicaid |
$1,220.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,946.50
|
| Rate for Payer: First Health Commercial |
$3,372.50
|
| Rate for Payer: Humana Commercial |
$3,017.50
|
| Rate for Payer: Humana KY Medicaid |
$1,220.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,233.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,619.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,245.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,100.50
|
| Rate for Payer: PHCS Commercial |
$3,408.00
|
| Rate for Payer: United Healthcare All Payer |
$3,124.00
|
|
|
LUNG VOLUME REDUCTION
|
Professional
|
Both
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,083.94 |
| Max. Negotiated Rate |
$3,550.00 |
| Rate for Payer: Aetna Commercial |
$2,479.97
|
| Rate for Payer: Anthem Medicaid |
$1,083.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,550.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,359.64
|
| Rate for Payer: Healthspan PPO |
$1,936.29
|
| Rate for Payer: Humana Medicaid |
$1,083.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,057.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,105.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,083.94
|
| Rate for Payer: Multiplan PHCS |
$2,130.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,485.00
|
| Rate for Payer: UHCCP Medicaid |
$1,242.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,094.78
|
|
|
LUNG VOLUME REDUCTION
|
Facility
|
IP
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$461.50 |
| Max. Negotiated Rate |
$3,408.00 |
| Rate for Payer: Aetna Commercial |
$2,733.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,946.50
|
| Rate for Payer: First Health Commercial |
$3,372.50
|
| Rate for Payer: Humana Commercial |
$3,017.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,619.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,100.50
|
| Rate for Payer: PHCS Commercial |
$3,408.00
|
| Rate for Payer: United Healthcare All Payer |
$3,124.00
|
|
|
LUNG VOLUME REDUCTION(P
|
Professional
|
Both
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
761P1193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,083.94 |
| Max. Negotiated Rate |
$3,550.00 |
| Rate for Payer: Aetna Commercial |
$2,479.97
|
| Rate for Payer: Anthem Medicaid |
$1,083.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,550.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,359.64
|
| Rate for Payer: Healthspan PPO |
$1,936.29
|
| Rate for Payer: Humana Medicaid |
$1,083.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,057.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,105.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,083.94
|
| Rate for Payer: Multiplan PHCS |
$2,130.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,485.00
|
| Rate for Payer: UHCCP Medicaid |
$1,242.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,094.78
|
|
|
LUPINE LOOP ANCHOR
|
Facility
|
IP
|
$3,309.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.24 |
| Max. Negotiated Rate |
$3,177.12 |
| Rate for Payer: Aetna Commercial |
$2,548.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,581.41
|
| Rate for Payer: Cash Price |
$1,654.75
|
| Rate for Payer: Cigna Commercial |
$2,746.88
|
| Rate for Payer: First Health Commercial |
$3,144.02
|
| Rate for Payer: Humana Commercial |
$2,813.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,713.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,442.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$992.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,912.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,482.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$661.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$430.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.94
|
| Rate for Payer: PHCS Commercial |
$3,177.12
|
| Rate for Payer: United Healthcare All Payer |
$2,912.36
|
|
|
LUPINE LOOP ANCHOR
|
Facility
|
OP
|
$3,309.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.24 |
| Max. Negotiated Rate |
$3,177.12 |
| Rate for Payer: Aetna Commercial |
$2,548.32
|
| Rate for Payer: Anthem Medicaid |
$1,138.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,581.41
|
| Rate for Payer: Cash Price |
$1,654.75
|
| Rate for Payer: Cigna Commercial |
$2,746.88
|
| Rate for Payer: First Health Commercial |
$3,144.02
|
| Rate for Payer: Humana Commercial |
$2,813.08
|
| Rate for Payer: Humana KY Medicaid |
$1,138.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,149.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,713.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,442.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$992.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,160.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,912.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,482.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$661.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$430.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.94
|
| Rate for Payer: PHCS Commercial |
$3,177.12
|
| Rate for Payer: United Healthcare All Payer |
$2,912.36
|
|
