|
LIPO (TRUNK)
|
Facility
|
OP
|
$800.00
|
|
| Hospital Charge Code |
22200051
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
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 |
$4,925.09 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| 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 |
$2,419.63 |
| 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 |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,487.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| 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 |
$3,382.66
|
| 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 |
$4,059.19
|
| 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 |
$5,628.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,121.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,854.73
|
| Rate for Payer: PHCS Commercial |
$6,754.41
|
| Rate for Payer: United Healthcare All Payer |
$6,191.54
|
|
|
LIPO TRUNK
|
Facility
|
IP
|
$7,035.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
76100229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,110.75 |
| 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 |
$5,628.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,121.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,854.73
|
| Rate for Payer: PHCS Commercial |
$6,754.41
|
| Rate for Payer: United Healthcare All Payer |
$6,191.54
|
|
|
LIPO (TRUNK) -80
|
Facility
|
IP
|
$400.00
|
|
| Hospital Charge Code |
22200379
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
LIPO (TRUNK) -80
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200379
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$280.00 |
| 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) -80
|
Facility
|
OP
|
$400.00
|
|
| Hospital Charge Code |
22200379
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
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 |
$1,400.72 |
| Rate for Payer: Aetna Commercial |
$1,400.72
|
| Rate for Payer: Anthem Medicaid |
$144.85
|
| 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
|
OP
|
$5,435.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
761T0229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,869.39 |
| 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 |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,239.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| 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 |
$3,382.66
|
| 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 |
$4,059.19
|
| 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 |
$4,348.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,729.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,750.73
|
| Rate for Payer: PHCS Commercial |
$5,218.41
|
| Rate for Payer: United Healthcare All Payer |
$4,783.54
|
|
|
LIPO TRUNK(T
|
Facility
|
IP
|
$5,435.84
|
|
|
Service Code
|
HCPCS 15877
|
| Hospital Charge Code |
761T0229
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,630.75 |
| 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 |
$4,348.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,729.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,750.73
|
| Rate for Payer: PHCS Commercial |
$5,218.41
|
| Rate for Payer: United Healthcare All Payer |
$4,783.54
|
|
|
LISTERIA SP TUF GENE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001300
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| 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 |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
LISTERIA SP TUF GENE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001300
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
LITHIUM
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.61 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Aetna Commercial |
$77.77
|
| Rate for Payer: Anthem Medicaid |
$6.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.61
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$83.83
|
| Rate for Payer: First Health Commercial |
$95.95
|
| Rate for Payer: Humana Commercial |
$85.85
|
| 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 |
$82.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.88
|
| Rate for Payer: Ohio Health Group HMO |
$75.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.69
|
| Rate for Payer: PHCS Commercial |
$96.96
|
| Rate for Payer: United Healthcare All Payer |
$88.88
|
|
|
LITHIUM
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$60.60 |
| Rate for Payer: Aetna Commercial |
$12.92
|
| Rate for Payer: Ambetter Exchange |
$6.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$6.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$6.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.93
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$5.78
|
| Rate for Payer: Healthspan PPO |
$6.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$6.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.61
|
| Rate for Payer: Multiplan PHCS |
$60.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8.59
|
| Rate for Payer: UHCCP Medicaid |
$35.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$6.61
|
|
|
LITHIUM
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS 80178
|
| Hospital Charge Code |
30000037
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Aetna Commercial |
$77.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$81.10
|
| Rate for Payer: Cash Price |
$50.50
|
| Rate for Payer: Cigna Commercial |
$83.83
|
| Rate for Payer: First Health Commercial |
$95.95
|
| Rate for Payer: Humana Commercial |
$85.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.88
|
| Rate for Payer: Ohio Health Group HMO |
$75.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.69
|
| Rate for Payer: PHCS Commercial |
$96.96
|
| Rate for Payer: United Healthcare All Payer |
$88.88
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 54852625
|
| Hospital Charge Code |
25000884
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
LITHIUM CARBONATE 150MG CAP
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 54852625
|
| Hospital Charge Code |
25000884
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| 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 |
$8.93 |
| Max. Negotiated Rate |
$28.56 |
| 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
|
| Rate for Payer: Humana Commercial |
$25.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.93
|
| 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 |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.53
|
| Rate for Payer: PHCS Commercial |
$28.56
|
| Rate for Payer: United Healthcare All Payer |
$26.18
|
|
|
LITHOBID (LITHIUM) 300MG/1TAB
|
Facility
|
OP
|
$29.75
|
|
|
Service Code
|
NDC 62559028001
|
| Hospital Charge Code |
25000887
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.93 |
| 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 |
$24.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.93
|
| 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 |
$23.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.53
|
| 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 |
$1.35 |
| 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 |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| 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 |
$1.35 |
| 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 |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| 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
|
$4,461.49
|
|
|
Service Code
|
CPT 52318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,186.78 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
|
|
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
|
$4,461.49
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,186.78 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
|
|
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 |
$2,940.00 |
| Rate for Payer: Aetna Commercial |
$915.91
|
| Rate for Payer: Ambetter Exchange |
$541.06
|
| 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 Individual/Medicaid |
$541.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$541.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$649.27
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$541.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.06
|
| 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 |
$703.38
|
| Rate for Payer: UHCCP Medicaid |
$365.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$541.06
|
|
|
LITHOTRIPSY, SHOCK WAVE
|
Facility
|
OP
|
$4,900.00
|
|
|
Service Code
|
HCPCS 50590
|
| Hospital Charge Code |
76102053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,685.11 |
| 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 |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| 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 |
$3,186.78
|
| 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 |
$3,824.14
|
| 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 |
$3,920.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,263.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,381.00
|
| Rate for Payer: PHCS Commercial |
$4,704.00
|
| Rate for Payer: United Healthcare All Payer |
$4,312.00
|
|
