|
LUTONIX DCB 7*150 5F
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
LUTONIX DCB 7*220 5F
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
LUTONIX DCB 7*220 5F
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
LUTONIX DCB 7*40*130
|
Facility
|
IP
|
$8,822.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,146.92 |
| Max. Negotiated Rate |
$8,469.60 |
| Rate for Payer: Aetna Commercial |
$6,793.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,881.55
|
| Rate for Payer: Cash Price |
$4,411.25
|
| Rate for Payer: Cigna Commercial |
$7,322.68
|
| Rate for Payer: First Health Commercial |
$8,381.38
|
| Rate for Payer: Humana Commercial |
$7,499.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,234.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,511.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,764.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,146.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,734.98
|
| Rate for Payer: PHCS Commercial |
$8,469.60
|
| Rate for Payer: United Healthcare All Payer |
$7,763.80
|
|
|
LUTONIX DCB 7*40*130
|
Facility
|
OP
|
$8,822.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,146.92 |
| Max. Negotiated Rate |
$8,469.60 |
| Rate for Payer: Aetna Commercial |
$6,793.32
|
| Rate for Payer: Anthem Medicaid |
$3,034.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,881.55
|
| Rate for Payer: Cash Price |
$4,411.25
|
| Rate for Payer: Cigna Commercial |
$7,322.68
|
| Rate for Payer: First Health Commercial |
$8,381.38
|
| Rate for Payer: Humana Commercial |
$7,499.12
|
| Rate for Payer: Humana KY Medicaid |
$3,034.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,064.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,234.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,511.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,094.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,764.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,146.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,734.98
|
| Rate for Payer: PHCS Commercial |
$8,469.60
|
| Rate for Payer: United Healthcare All Payer |
$7,763.80
|
|
|
LUTONIX DCB 7*60*130
|
Facility
|
IP
|
$8,822.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,146.92 |
| Max. Negotiated Rate |
$8,469.60 |
| Rate for Payer: Aetna Commercial |
$6,793.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,881.55
|
| Rate for Payer: Cash Price |
$4,411.25
|
| Rate for Payer: Cigna Commercial |
$7,322.68
|
| Rate for Payer: First Health Commercial |
$8,381.38
|
| Rate for Payer: Humana Commercial |
$7,499.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,234.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,511.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,764.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,146.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,734.98
|
| Rate for Payer: PHCS Commercial |
$8,469.60
|
| Rate for Payer: United Healthcare All Payer |
$7,763.80
|
|
|
LUTONIX DCB 7*60*130
|
Facility
|
OP
|
$8,822.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,146.92 |
| Max. Negotiated Rate |
$8,469.60 |
| Rate for Payer: Aetna Commercial |
$6,793.32
|
| Rate for Payer: Anthem Medicaid |
$3,034.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,881.55
|
| Rate for Payer: Cash Price |
$4,411.25
|
| Rate for Payer: Cigna Commercial |
$7,322.68
|
| Rate for Payer: First Health Commercial |
$8,381.38
|
| Rate for Payer: Humana Commercial |
$7,499.12
|
| Rate for Payer: Humana KY Medicaid |
$3,034.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,064.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,234.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,511.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,094.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,764.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,146.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,734.98
|
| Rate for Payer: PHCS Commercial |
$8,469.60
|
| Rate for Payer: United Healthcare All Payer |
$7,763.80
|
|
|
LUTONIX DCB 7*80 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX DCB 7*80 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUVOX 25MG TABLET
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
25000929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX 25MG TABLET
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
25000929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX EQUIV 50MG TABLET
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 832167111
|
| Hospital Charge Code |
25000930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX EQUIV 50MG TABLET
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 832167111
|
| Hospital Charge Code |
25000930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$152.64 |
| Rate for Payer: Aetna Commercial |
$122.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$131.97
|
| Rate for Payer: First Health Commercial |
$151.05
|
| Rate for Payer: Humana Commercial |
$135.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$130.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$117.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.92
|
| Rate for Payer: Ohio Health Group HMO |
$119.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.29
|
| Rate for Payer: PHCS Commercial |
$152.64
|
| Rate for Payer: United Healthcare All Payer |
$139.92
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Professional
|
Both
|
$159.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$19.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$15.10
|
| Rate for Payer: Healthspan PPO |
$17.85
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.22
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$152.64 |
| Rate for Payer: Aetna Commercial |
$122.43
|
| Rate for Payer: Anthem Medicaid |
$17.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.03
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$131.97
|
| Rate for Payer: First Health Commercial |
$151.05
|
| Rate for Payer: Humana Commercial |
$135.15
|
| Rate for Payer: Humana KY Medicaid |
$17.03
|
| Rate for Payer: Humana Medicare Advantage |
$17.03
|
| Rate for Payer: Kentucky WC Medicaid |
$17.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$130.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$117.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.92
|
| Rate for Payer: Ohio Health Group HMO |
$119.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.29
|
| Rate for Payer: PHCS Commercial |
$152.64
|
| Rate for Payer: United Healthcare All Payer |
$139.92
|
|
|
LYMPHAZURIN1% 10MG/ML 5ML VIAL
|
Facility
|
IP
|
$2,810.89
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.42 |
| Max. Negotiated Rate |
$2,698.45 |
| Rate for Payer: Aetna Commercial |
$2,164.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,192.49
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cigna Commercial |
$2,333.04
|
| Rate for Payer: First Health Commercial |
$2,670.35
|
| Rate for Payer: Humana Commercial |
$2,389.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,304.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,074.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$843.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,473.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,108.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$562.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$871.38
|
| Rate for Payer: PHCS Commercial |
$2,698.45
|
| Rate for Payer: United Healthcare All Payer |
$2,473.58
|
|
|
LYMPHAZURIN1% 10MG/ML 5ML VIAL
|
Facility
|
OP
|
$2,810.89
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.95 |
| Max. Negotiated Rate |
$2,698.45 |
| Rate for Payer: Aetna Commercial |
$2,164.39
|
| Rate for Payer: Anthem Medicaid |
$966.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,192.49
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.73
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cigna Commercial |
$2,333.04
|
| Rate for Payer: First Health Commercial |
$2,670.35
|
| Rate for Payer: Humana Commercial |
$2,389.26
|
| Rate for Payer: Humana KY Medicaid |
$966.67
|
| Rate for Payer: Humana Medicare Advantage |
$7.95
|
| Rate for Payer: Kentucky WC Medicaid |
$976.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,304.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,074.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$986.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,473.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,108.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$562.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$871.38
|
| Rate for Payer: PHCS Commercial |
$2,698.45
|
| Rate for Payer: United Healthcare All Payer |
$2,473.58
|
|
|
LYMPH NODE MBI IMAGING
|
Facility
|
OP
|
$1,621.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$210.73 |
| Max. Negotiated Rate |
$1,556.16 |
| Rate for Payer: Aetna Commercial |
$1,248.17
|
| Rate for Payer: Anthem Medicaid |
$557.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$467.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,264.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$654.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.99
|
| Rate for Payer: Cash Price |
$810.50
|
| Rate for Payer: Cash Price |
$810.50
|
| Rate for Payer: Cigna Commercial |
$1,345.43
|
| Rate for Payer: First Health Commercial |
$1,539.95
|
| Rate for Payer: Humana Commercial |
$1,377.85
|
| Rate for Payer: Humana KY Medicaid |
$557.46
|
| Rate for Payer: Humana Medicare Advantage |
$467.40
|
| Rate for Payer: Kentucky WC Medicaid |
$563.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,329.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,196.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$568.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,426.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,215.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$324.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$502.51
|
| Rate for Payer: PHCS Commercial |
$1,556.16
|
| Rate for Payer: United Healthcare All Payer |
$1,426.48
|
|
|
LYMPH NODE MBI IMAGING
|
Facility
|
IP
|
$1,621.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$210.73 |
| Max. Negotiated Rate |
$1,556.16 |
| Rate for Payer: Aetna Commercial |
$1,248.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,264.38
|
| Rate for Payer: Cash Price |
$810.50
|
| Rate for Payer: Cigna Commercial |
$1,345.43
|
| Rate for Payer: First Health Commercial |
$1,539.95
|
| Rate for Payer: Humana Commercial |
$1,377.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,329.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,196.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$486.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,426.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,215.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$324.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$502.51
|
| Rate for Payer: PHCS Commercial |
$1,556.16
|
| Rate for Payer: United Healthcare All Payer |
$1,426.48
|
|
|
LYMPH NODE MBI IMAGING
|
Professional
|
Both
|
$1,621.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$1,621.00 |
| Rate for Payer: Aetna Commercial |
$491.15
|
| Rate for Payer: Anthem Medicaid |
$140.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,621.00
|
| Rate for Payer: Cash Price |
$810.50
|
| Rate for Payer: Cash Price |
$810.50
|
| Rate for Payer: Cigna Commercial |
$377.41
|
| Rate for Payer: Healthspan PPO |
$490.90
|
| Rate for Payer: Humana Medicaid |
$140.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$143.29
|
| Rate for Payer: Molina Healthcare Passport |
$140.48
|
| Rate for Payer: Multiplan PHCS |
$972.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,134.70
|
| Rate for Payer: UHCCP Medicaid |
$567.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$141.88
|
|
|
LYMPH NODE MBI IMAGING(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340P0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna Commercial |
$491.15
|
| Rate for Payer: Anthem Medicaid |
$140.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$377.41
|
| Rate for Payer: Healthspan PPO |
$490.90
|
| Rate for Payer: Humana Medicaid |
$140.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$143.29
|
| Rate for Payer: Molina Healthcare Passport |
$140.48
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$141.88
|
|
|
LYMPH NODE MBI IMAGING(T
|
Facility
|
OP
|
$1,446.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340T0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$187.98 |
| Max. Negotiated Rate |
$1,388.16 |
| Rate for Payer: Aetna Commercial |
$1,113.42
|
| Rate for Payer: Anthem Medicaid |
$497.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$467.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,127.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$654.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.99
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$1,200.18
|
| Rate for Payer: First Health Commercial |
$1,373.70
|
| Rate for Payer: Humana Commercial |
$1,229.10
|
| Rate for Payer: Humana KY Medicaid |
$497.28
|
| Rate for Payer: Humana Medicare Advantage |
$467.40
|
| Rate for Payer: Kentucky WC Medicaid |
$502.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,185.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,067.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$507.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,272.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,084.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$448.26
|
| Rate for Payer: PHCS Commercial |
$1,388.16
|
| Rate for Payer: United Healthcare All Payer |
$1,272.48
|
|
|
LYMPH NODE MBI IMAGING(T
|
Facility
|
IP
|
$1,446.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340T0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$187.98 |
| Max. Negotiated Rate |
$1,388.16 |
| Rate for Payer: Aetna Commercial |
$1,113.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,127.88
|
| Rate for Payer: Cash Price |
$723.00
|
| Rate for Payer: Cigna Commercial |
$1,200.18
|
| Rate for Payer: First Health Commercial |
$1,373.70
|
| Rate for Payer: Humana Commercial |
$1,229.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,185.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,067.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$433.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,272.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,084.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$448.26
|
| Rate for Payer: PHCS Commercial |
$1,388.16
|
| Rate for Payer: United Healthcare All Payer |
$1,272.48
|
|
|
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$26,111.57
|
|
|
Service Code
|
MSDRG 821
|
| Min. Negotiated Rate |
$17,718.56 |
| Max. Negotiated Rate |
$26,111.57 |
| Rate for Payer: Anthem Medicaid |
$17,718.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18,651.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$26,111.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$25,179.01
|
| Rate for Payer: Humana KY Medicaid |
$17,718.56
|
| Rate for Payer: Humana Medicare Advantage |
$18,651.12
|
| Rate for Payer: Kentucky WC Medicaid |
$17,895.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,381.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,072.94
|
|
