|
LUMBAR PUNCTURE DIAG(T
|
Facility
|
IP
|
$1,045.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
761T2291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$313.50 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$909.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.05
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
|
LUMBAR SPINE 2-3V
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
32000052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$423.36 |
| Rate for Payer: Aetna Commercial |
$339.57
|
| Rate for Payer: Anthem Medicaid |
$151.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$366.03
|
| Rate for Payer: First Health Commercial |
$418.95
|
| Rate for Payer: Humana Commercial |
$374.85
|
| Rate for Payer: Humana KY Medicaid |
$151.66
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$153.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$361.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$325.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$154.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.08
|
| Rate for Payer: Ohio Health Group HMO |
$330.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.29
|
| Rate for Payer: PHCS Commercial |
$423.36
|
| Rate for Payer: United Healthcare All Payer |
$388.08
|
|
|
LUMBAR SPINE 2-3V
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
32000052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$264.60 |
| Rate for Payer: Aetna Commercial |
$58.54
|
| Rate for Payer: Ambetter Exchange |
$35.78
|
| Rate for Payer: Anthem Medicaid |
$27.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.94
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$56.01
|
| Rate for Payer: Healthspan PPO |
$54.85
|
| Rate for Payer: Humana Medicaid |
$27.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.07
|
| Rate for Payer: Molina Healthcare Passport |
$27.52
|
| Rate for Payer: Multiplan PHCS |
$264.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.51
|
| Rate for Payer: UHCCP Medicaid |
$154.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.78
|
|
|
LUMBAR SPINE 2-3V
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
32000052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$423.36 |
| Rate for Payer: Aetna Commercial |
$339.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.98
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cigna Commercial |
$366.03
|
| Rate for Payer: First Health Commercial |
$418.95
|
| Rate for Payer: Humana Commercial |
$374.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$361.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$325.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.08
|
| Rate for Payer: Ohio Health Group HMO |
$330.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.29
|
| Rate for Payer: PHCS Commercial |
$423.36
|
| Rate for Payer: United Healthcare All Payer |
$388.08
|
|
|
LUMBAR SPINE 2-3V(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
320P0052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$58.54 |
| Rate for Payer: Aetna Commercial |
$58.54
|
| Rate for Payer: Ambetter Exchange |
$35.78
|
| Rate for Payer: Anthem Medicaid |
$27.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.94
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$56.01
|
| Rate for Payer: Healthspan PPO |
$54.85
|
| Rate for Payer: Humana Medicaid |
$27.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.07
|
| Rate for Payer: Molina Healthcare Passport |
$27.52
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.51
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.78
|
|
|
LUMBAR SPINE 2-3V(T
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
320T0052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$340.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.79
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
LUMBAR SPINE 2-3V(T
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
HCPCS 72100
|
| Hospital Charge Code |
320T0052
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem Medicaid |
$134.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Humana KY Medicaid |
$134.46
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$135.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$340.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.79
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
LUMBOSACRAL SPINE MIN 4VWS
|
Professional
|
Both
|
$566.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
32000053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$339.60 |
| Rate for Payer: Aetna Commercial |
$81.75
|
| Rate for Payer: Ambetter Exchange |
$46.80
|
| Rate for Payer: Anthem Medicaid |
$38.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$46.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$46.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.16
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cigna Commercial |
$77.30
|
| Rate for Payer: Healthspan PPO |
$76.61
|
| Rate for Payer: Humana Medicaid |
$38.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$46.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.89
|
| Rate for Payer: Molina Healthcare Passport |
$38.13
|
| Rate for Payer: Multiplan PHCS |
$339.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$60.84
|
| Rate for Payer: UHCCP Medicaid |
$198.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$46.80
|
|
|
LUMBOSACRAL SPINE MIN 4VWS
|
Facility
|
OP
|
$566.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
32000053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$543.36 |
| Rate for Payer: Aetna Commercial |
$435.82
|
| Rate for Payer: Anthem Medicaid |
$194.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$441.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cigna Commercial |
$469.78
|
| Rate for Payer: First Health Commercial |
$537.70
|
| Rate for Payer: Humana Commercial |
$481.10
|
| Rate for Payer: Humana KY Medicaid |
$194.65
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$196.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$464.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$417.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$498.08
|
| Rate for Payer: Ohio Health Group HMO |
$424.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.54
|
| Rate for Payer: PHCS Commercial |
$543.36
|
| Rate for Payer: United Healthcare All Payer |
$498.08
|
|
|
LUMBOSACRAL SPINE MIN 4VWS
|
Facility
|
IP
|
$566.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
32000053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$169.80 |
| Max. Negotiated Rate |
$543.36 |
| Rate for Payer: Aetna Commercial |
$435.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$441.48
|
| Rate for Payer: Cash Price |
$283.00
|
| Rate for Payer: Cigna Commercial |
$469.78
|
| Rate for Payer: First Health Commercial |
$537.70
|
| Rate for Payer: Humana Commercial |
$481.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$464.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$417.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$498.08
|
| Rate for Payer: Ohio Health Group HMO |
$424.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.54
|
| Rate for Payer: PHCS Commercial |
$543.36
|
| Rate for Payer: United Healthcare All Payer |
$498.08
|
|
|
LUMBOSACRAL SPINE MIN 4VWS(P
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
320P0053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$81.75 |
| Rate for Payer: Aetna Commercial |
$81.75
|
| Rate for Payer: Ambetter Exchange |
$46.80
|
| Rate for Payer: Anthem Medicaid |
$38.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$46.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$46.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.16
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$77.30
|
| Rate for Payer: Healthspan PPO |
$76.61
|
| Rate for Payer: Humana Medicaid |
$38.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$46.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.89
|
| Rate for Payer: Molina Healthcare Passport |
$38.13
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$60.84
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$46.80
|
|
|
LUMBOSACRAL SPINE MIN 4VWS(T
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
320T0053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.80 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.14
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
LUMBOSACRAL SPINE MIN 4VWS(T
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
HCPCS 72110
|
| Hospital Charge Code |
320T0053
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem Medicaid |
$174.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Humana KY Medicaid |
$174.01
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$175.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.14
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
LUMIGAN 0.01% EYE DROPS
|
Facility
|
IP
|
$17.38
|
|
|
Service Code
|
NDC 23320503
|
| Hospital Charge Code |
25000924
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$16.68 |
| Rate for Payer: Aetna Commercial |
$13.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.56
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Cigna Commercial |
$14.43
|
| Rate for Payer: First Health Commercial |
$16.51
|
| Rate for Payer: Humana Commercial |
$14.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.29
|
| Rate for Payer: Ohio Health Group HMO |
$13.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.99
|
| Rate for Payer: PHCS Commercial |
$16.68
|
| Rate for Payer: United Healthcare All Payer |
$15.29
|
|
|
LUMIGAN 0.01% EYE DROPS
|
Facility
|
OP
|
$17.38
|
|
|
Service Code
|
NDC 23320503
|
| Hospital Charge Code |
25000924
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$16.68 |
| Rate for Payer: Aetna Commercial |
$13.38
|
| Rate for Payer: Anthem Medicaid |
$5.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13.56
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: Cigna Commercial |
$14.43
|
| Rate for Payer: First Health Commercial |
$16.51
|
| Rate for Payer: Humana Commercial |
$14.77
|
| Rate for Payer: Humana KY Medicaid |
$5.98
|
| Rate for Payer: Kentucky WC Medicaid |
$6.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$15.29
|
| Rate for Payer: Ohio Health Group HMO |
$13.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.99
|
| Rate for Payer: PHCS Commercial |
$16.68
|
| Rate for Payer: United Healthcare All Payer |
$15.29
|
|
|
LUNDERQUIST TM WIRE GUIDE
|
Facility
|
IP
|
$1,538.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.46 |
| Max. Negotiated Rate |
$1,476.67 |
| Rate for Payer: Aetna Commercial |
$1,184.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,199.80
|
| Rate for Payer: Cash Price |
$769.10
|
| Rate for Payer: Cigna Commercial |
$1,276.71
|
| Rate for Payer: First Health Commercial |
$1,461.29
|
| Rate for Payer: Humana Commercial |
$1,307.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,261.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,135.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$461.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,353.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,153.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,230.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,338.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.36
|
| Rate for Payer: PHCS Commercial |
$1,476.67
|
| Rate for Payer: United Healthcare All Payer |
$1,353.62
|
|
|
LUNDERQUIST TM WIRE GUIDE
|
Facility
|
OP
|
$1,538.20
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.46 |
| Max. Negotiated Rate |
$1,476.67 |
| Rate for Payer: Aetna Commercial |
$1,184.41
|
| Rate for Payer: Anthem Medicaid |
$528.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,199.80
|
| Rate for Payer: Cash Price |
$769.10
|
| Rate for Payer: Cigna Commercial |
$1,276.71
|
| Rate for Payer: First Health Commercial |
$1,461.29
|
| Rate for Payer: Humana Commercial |
$1,307.47
|
| Rate for Payer: Humana KY Medicaid |
$528.99
|
| Rate for Payer: Kentucky WC Medicaid |
$534.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,261.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,135.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$461.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$539.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,353.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,153.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,230.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,338.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.36
|
| Rate for Payer: PHCS Commercial |
$1,476.67
|
| Rate for Payer: United Healthcare All Payer |
$1,353.62
|
|
|
LUNDERQUIST WIRE 260CM SS
|
Facility
|
IP
|
$2,001.48
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.44 |
| Max. Negotiated Rate |
$1,921.42 |
| Rate for Payer: Aetna Commercial |
$1,541.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,561.15
|
| Rate for Payer: Cash Price |
$1,000.74
|
| Rate for Payer: Cigna Commercial |
$1,661.23
|
| Rate for Payer: First Health Commercial |
$1,901.41
|
| Rate for Payer: Humana Commercial |
$1,701.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,641.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,477.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,761.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,501.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,601.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,741.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,381.02
|
| Rate for Payer: PHCS Commercial |
$1,921.42
|
| Rate for Payer: United Healthcare All Payer |
$1,761.30
|
|
|
LUNDERQUIST WIRE 260CM SS
|
Facility
|
OP
|
$2,001.48
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.44 |
| Max. Negotiated Rate |
$1,921.42 |
| Rate for Payer: Aetna Commercial |
$1,541.14
|
| Rate for Payer: Anthem Medicaid |
$688.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,561.15
|
| Rate for Payer: Cash Price |
$1,000.74
|
| Rate for Payer: Cigna Commercial |
$1,661.23
|
| Rate for Payer: First Health Commercial |
$1,901.41
|
| Rate for Payer: Humana Commercial |
$1,701.26
|
| Rate for Payer: Humana KY Medicaid |
$688.31
|
| Rate for Payer: Kentucky WC Medicaid |
$695.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,641.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,477.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$702.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,761.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,501.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,601.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,741.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,381.02
|
| Rate for Payer: PHCS Commercial |
$1,921.42
|
| Rate for Payer: United Healthcare All Payer |
$1,761.30
|
|
|
LUNDRQST WR TSCMG-35-300-LESDC
|
Facility
|
IP
|
$1,722.56
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.77 |
| Max. Negotiated Rate |
$1,653.66 |
| Rate for Payer: Aetna Commercial |
$1,326.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,343.60
|
| Rate for Payer: Cash Price |
$861.28
|
| Rate for Payer: Cigna Commercial |
$1,429.72
|
| Rate for Payer: First Health Commercial |
$1,636.43
|
| Rate for Payer: Humana Commercial |
$1,464.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,412.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,271.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$516.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,515.85
|
| Rate for Payer: Ohio Health Group HMO |
$1,291.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,378.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,498.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,188.57
|
| Rate for Payer: PHCS Commercial |
$1,653.66
|
| Rate for Payer: United Healthcare All Payer |
$1,515.85
|
|
|
LUNDRQST WR TSCMG-35-300-LESDC
|
Facility
|
OP
|
$1,722.56
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.77 |
| Max. Negotiated Rate |
$1,653.66 |
| Rate for Payer: Aetna Commercial |
$1,326.37
|
| Rate for Payer: Anthem Medicaid |
$592.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,343.60
|
| Rate for Payer: Cash Price |
$861.28
|
| Rate for Payer: Cigna Commercial |
$1,429.72
|
| Rate for Payer: First Health Commercial |
$1,636.43
|
| Rate for Payer: Humana Commercial |
$1,464.18
|
| Rate for Payer: Humana KY Medicaid |
$592.39
|
| Rate for Payer: Kentucky WC Medicaid |
$598.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,412.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,271.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$516.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$604.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,515.85
|
| Rate for Payer: Ohio Health Group HMO |
$1,291.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,378.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,498.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,188.57
|
| Rate for Payer: PHCS Commercial |
$1,653.66
|
| Rate for Payer: United Healthcare All Payer |
$1,515.85
|
|
|
LUNESTA (ESZOPICLONE) 1MG TAB
|
Facility
|
IP
|
$60.16
|
|
|
Service Code
|
NDC 65862096730
|
| Hospital Charge Code |
25000925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| 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 |
$48.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.51
|
| Rate for Payer: PHCS Commercial |
$57.75
|
| Rate for Payer: United Healthcare All Payer |
$52.94
|
|
|
LUNESTA (ESZOPICLONE) 1MG TAB
|
Facility
|
OP
|
$60.16
|
|
|
Service Code
|
NDC 65862096730
|
| Hospital Charge Code |
25000925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.75 |
| 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
|
| 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 |
$48.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.51
|
| 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 |
$18.15 |
| Max. Negotiated Rate |
$58.08 |
| Rate for Payer: Aetna Commercial |
$46.59
|
| 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 |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.74
|
| 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 |
$18.15 |
| Max. Negotiated Rate |
$58.08 |
| Rate for Payer: Aetna Commercial |
$46.59
|
| 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 |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.74
|
| Rate for Payer: PHCS Commercial |
$58.08
|
| Rate for Payer: United Healthcare All Payer |
$53.24
|
|
