|
LUNESTA (ESZOPICLONE) 3MG TAB
|
Facility
|
OP
|
$60.18
|
|
|
Service Code
|
NDC 65862096901
|
| Hospital Charge Code |
25000927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Humana KY Medicaid |
$20.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
LUNESTA (ESZOPICLONE) 3MG TAB
|
Facility
|
IP
|
$60.18
|
|
|
Service Code
|
NDC 65862096901
|
| Hospital Charge Code |
25000927
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Facility
|
IP
|
$1,235.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$370.50 |
| Max. Negotiated Rate |
$1,185.60 |
| Rate for Payer: Aetna Commercial |
$950.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$963.30
|
| Rate for Payer: Cash Price |
$617.50
|
| Rate for Payer: Cigna Commercial |
$1,025.05
|
| Rate for Payer: First Health Commercial |
$1,173.25
|
| Rate for Payer: Humana Commercial |
$1,049.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,012.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$911.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$370.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,086.80
|
| Rate for Payer: Ohio Health Group HMO |
$926.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,074.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.15
|
| Rate for Payer: PHCS Commercial |
$1,185.60
|
| Rate for Payer: United Healthcare All Payer |
$1,086.80
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Professional
|
Both
|
$1,235.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$38.52 |
| Max. Negotiated Rate |
$741.00 |
| Rate for Payer: Ambetter Exchange |
$162.70
|
| Rate for Payer: Anthem Medicaid |
$151.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$162.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$162.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.24
|
| Rate for Payer: Cash Price |
$617.50
|
| Rate for Payer: Cash Price |
$617.50
|
| Rate for Payer: Cigna Commercial |
$321.99
|
| Rate for Payer: Healthspan PPO |
$214.10
|
| Rate for Payer: Humana Medicaid |
$151.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$162.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.48
|
| Rate for Payer: Molina Healthcare Passport |
$151.45
|
| Rate for Payer: Multiplan PHCS |
$741.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$211.51
|
| Rate for Payer: UHCCP Medicaid |
$432.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$162.70
|
|
|
LUNG QUANTITATIVE PERFUSION
|
Facility
|
OP
|
$1,235.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
34000026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,185.60 |
| Rate for Payer: Aetna Commercial |
$950.95
|
| Rate for Payer: Anthem Medicaid |
$424.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$963.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$617.50
|
| Rate for Payer: Cash Price |
$617.50
|
| Rate for Payer: Cigna Commercial |
$1,025.05
|
| Rate for Payer: First Health Commercial |
$1,173.25
|
| Rate for Payer: Humana Commercial |
$1,049.75
|
| Rate for Payer: Humana KY Medicaid |
$424.72
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$429.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,012.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$911.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$433.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,086.80
|
| Rate for Payer: Ohio Health Group HMO |
$926.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,074.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.15
|
| Rate for Payer: PHCS Commercial |
$1,185.60
|
| Rate for Payer: United Healthcare All Payer |
$1,086.80
|
|
|
LUNG QUANTITATIVE PERFUSION(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340P0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$38.52 |
| Max. Negotiated Rate |
$321.99 |
| Rate for Payer: Ambetter Exchange |
$162.70
|
| Rate for Payer: Anthem Medicaid |
$151.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$162.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$162.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.24
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$321.99
|
| Rate for Payer: Healthspan PPO |
$214.10
|
| Rate for Payer: Humana Medicaid |
$151.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$162.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.48
|
| Rate for Payer: Molina Healthcare Passport |
$151.45
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$211.51
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$162.70
|
|
|
LUNG QUANTITATIVE PERFUSION(T
|
Facility
|
IP
|
$1,085.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340T0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$325.50 |
| Max. Negotiated Rate |
$1,041.60 |
| Rate for Payer: Aetna Commercial |
$835.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$846.30
|
| Rate for Payer: Cash Price |
$542.50
|
| Rate for Payer: Cigna Commercial |
$900.55
|
| Rate for Payer: First Health Commercial |
$1,030.75
|
| Rate for Payer: Humana Commercial |
$922.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$889.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$800.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$954.80
|
| Rate for Payer: Ohio Health Group HMO |
$813.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$868.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$943.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$748.65
|
| Rate for Payer: PHCS Commercial |
$1,041.60
|
| Rate for Payer: United Healthcare All Payer |
$954.80
|
|
|
LUNG QUANTITATIVE PERFUSION(T
|
Facility
|
OP
|
$1,085.00
|
|
|
Service Code
|
HCPCS 78597
|
| Hospital Charge Code |
340T0026
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,041.60 |
| Rate for Payer: Aetna Commercial |
$835.45
|
| Rate for Payer: Anthem Medicaid |
$373.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$846.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$542.50
|
| Rate for Payer: Cash Price |
$542.50
|
| Rate for Payer: Cigna Commercial |
$900.55
|
| Rate for Payer: First Health Commercial |
$1,030.75
|
| Rate for Payer: Humana Commercial |
$922.25
|
| Rate for Payer: Humana KY Medicaid |
$373.13
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$376.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$889.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$800.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$380.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$954.80
|
| Rate for Payer: Ohio Health Group HMO |
$813.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$868.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$943.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$748.65
|
| Rate for Payer: PHCS Commercial |
$1,041.60
|
| Rate for Payer: United Healthcare All Payer |
$954.80
|
|
|
LUNG VENTILATION SCAN
|
Facility
|
IP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$1,044.48 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
LUNG VENTILATION SCAN
|
Facility
|
OP
|
$1,088.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$1,044.48 |
| Rate for Payer: Aetna Commercial |
$837.76
|
| Rate for Payer: Anthem Medicaid |
$374.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$848.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$903.04
|
| Rate for Payer: First Health Commercial |
$1,033.60
|
| Rate for Payer: Humana Commercial |
$924.80
|
| Rate for Payer: Humana KY Medicaid |
$374.16
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$377.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$802.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$381.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$957.44
|
| Rate for Payer: Ohio Health Group HMO |
$816.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$870.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$946.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.72
|
| Rate for Payer: PHCS Commercial |
$1,044.48
|
| Rate for Payer: United Healthcare All Payer |
$957.44
|
|
|
LUNG VENTILATION SCAN
|
Professional
|
Both
|
$1,088.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
34000023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Ambetter Exchange |
$150.71
|
| Rate for Payer: Anthem Medicaid |
$133.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$180.85
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna Commercial |
$285.10
|
| Rate for Payer: Healthspan PPO |
$189.71
|
| Rate for Payer: Humana Medicaid |
$133.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$150.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.53
|
| Rate for Payer: Molina Healthcare Passport |
$133.85
|
| Rate for Payer: Multiplan PHCS |
$652.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$195.92
|
| Rate for Payer: UHCCP Medicaid |
$380.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.71
|
|
|
LUNG VENTILATION SCAN(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340P0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$285.10 |
| Rate for Payer: Ambetter Exchange |
$150.71
|
| Rate for Payer: Anthem Medicaid |
$133.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$180.85
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$285.10
|
| Rate for Payer: Healthspan PPO |
$189.71
|
| Rate for Payer: Humana Medicaid |
$133.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$26.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$150.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.53
|
| Rate for Payer: Molina Healthcare Passport |
$133.85
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$195.92
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.71
|
|
|
LUNG VENTILATION SCAN(T
|
Facility
|
IP
|
$938.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340T0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$281.40 |
| Max. Negotiated Rate |
$900.48 |
| Rate for Payer: Aetna Commercial |
$722.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$731.64
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cigna Commercial |
$778.54
|
| Rate for Payer: First Health Commercial |
$891.10
|
| Rate for Payer: Humana Commercial |
$797.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$769.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$692.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$281.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$825.44
|
| Rate for Payer: Ohio Health Group HMO |
$703.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$816.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.22
|
| Rate for Payer: PHCS Commercial |
$900.48
|
| Rate for Payer: United Healthcare All Payer |
$825.44
|
|
|
LUNG VENTILATION SCAN(T
|
Facility
|
OP
|
$938.00
|
|
|
Service Code
|
HCPCS 78579
|
| Hospital Charge Code |
340T0023
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$322.58 |
| Max. Negotiated Rate |
$900.48 |
| Rate for Payer: Aetna Commercial |
$722.26
|
| Rate for Payer: Anthem Medicaid |
$322.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$371.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$731.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$519.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$501.23
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: Cigna Commercial |
$778.54
|
| Rate for Payer: First Health Commercial |
$891.10
|
| Rate for Payer: Humana Commercial |
$797.30
|
| Rate for Payer: Humana KY Medicaid |
$322.58
|
| Rate for Payer: Humana Medicare Advantage |
$371.28
|
| Rate for Payer: Kentucky WC Medicaid |
$325.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$769.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$692.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$329.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$825.44
|
| Rate for Payer: Ohio Health Group HMO |
$703.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$816.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$647.22
|
| Rate for Payer: PHCS Commercial |
$900.48
|
| Rate for Payer: United Healthcare All Payer |
$825.44
|
|
|
LUNG VOLUME REDUCTION
|
Facility
|
OP
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,065.00 |
| Max. Negotiated Rate |
$3,408.00 |
| Rate for Payer: Aetna Commercial |
$2,733.50
|
| Rate for Payer: Anthem Medicaid |
$1,220.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,946.50
|
| Rate for Payer: First Health Commercial |
$3,372.50
|
| Rate for Payer: Humana Commercial |
$3,017.50
|
| Rate for Payer: Humana KY Medicaid |
$1,220.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,233.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,619.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,245.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,088.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,449.50
|
| Rate for Payer: PHCS Commercial |
$3,408.00
|
| Rate for Payer: United Healthcare All Payer |
$3,124.00
|
|
|
LUNG VOLUME REDUCTION
|
Facility
|
IP
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,065.00 |
| Max. Negotiated Rate |
$3,408.00 |
| Rate for Payer: Aetna Commercial |
$2,733.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,946.50
|
| Rate for Payer: First Health Commercial |
$3,372.50
|
| Rate for Payer: Humana Commercial |
$3,017.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,619.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,088.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,449.50
|
| Rate for Payer: PHCS Commercial |
$3,408.00
|
| Rate for Payer: United Healthcare All Payer |
$3,124.00
|
|
|
LUNG VOLUME REDUCTION
|
Professional
|
Both
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
76101193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,083.94 |
| Max. Negotiated Rate |
$2,479.97 |
| Rate for Payer: Aetna Commercial |
$2,479.97
|
| Rate for Payer: Ambetter Exchange |
$1,387.99
|
| Rate for Payer: Anthem Medicaid |
$1,083.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,387.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,387.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,665.59
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,359.64
|
| Rate for Payer: Healthspan PPO |
$1,936.29
|
| Rate for Payer: Humana Medicaid |
$1,083.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,057.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,387.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,105.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,083.94
|
| Rate for Payer: Multiplan PHCS |
$2,130.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,804.39
|
| Rate for Payer: UHCCP Medicaid |
$1,242.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,094.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,387.99
|
|
|
LUNG VOLUME REDUCTION(P
|
Professional
|
Both
|
$3,550.00
|
|
|
Service Code
|
HCPCS 32491
|
| Hospital Charge Code |
761P1193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,083.94 |
| Max. Negotiated Rate |
$2,479.97 |
| Rate for Payer: Aetna Commercial |
$2,479.97
|
| Rate for Payer: Ambetter Exchange |
$1,387.99
|
| Rate for Payer: Anthem Medicaid |
$1,083.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,387.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,387.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,665.59
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cash Price |
$1,775.00
|
| Rate for Payer: Cigna Commercial |
$2,359.64
|
| Rate for Payer: Healthspan PPO |
$1,936.29
|
| Rate for Payer: Humana Medicaid |
$1,083.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,057.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,387.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,105.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,083.94
|
| Rate for Payer: Multiplan PHCS |
$2,130.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,804.39
|
| Rate for Payer: UHCCP Medicaid |
$1,242.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,094.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,387.99
|
|
|
LUPINE LOOP ANCHOR
|
Facility
|
OP
|
$3,188.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$956.62 |
| Max. Negotiated Rate |
$3,061.20 |
| Rate for Payer: Aetna Commercial |
$2,455.34
|
| Rate for Payer: Anthem Medicaid |
$1,096.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.22
|
| Rate for Payer: Cash Price |
$1,594.38
|
| Rate for Payer: Cigna Commercial |
$2,646.66
|
| Rate for Payer: First Health Commercial |
$3,029.31
|
| Rate for Payer: Humana Commercial |
$2,710.44
|
| Rate for Payer: Humana KY Medicaid |
$1,096.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,107.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,614.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,118.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,391.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.24
|
| Rate for Payer: PHCS Commercial |
$3,061.20
|
| Rate for Payer: United Healthcare All Payer |
$2,806.10
|
|
|
LUPINE LOOP ANCHOR
|
Facility
|
IP
|
$3,188.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$956.62 |
| Max. Negotiated Rate |
$3,061.20 |
| Rate for Payer: Aetna Commercial |
$2,455.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,487.22
|
| Rate for Payer: Cash Price |
$1,594.38
|
| Rate for Payer: Cigna Commercial |
$2,646.66
|
| Rate for Payer: First Health Commercial |
$3,029.31
|
| Rate for Payer: Humana Commercial |
$2,710.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,614.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,353.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$956.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,806.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,391.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,551.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,774.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,200.24
|
| Rate for Payer: PHCS Commercial |
$3,061.20
|
| Rate for Payer: United Healthcare All Payer |
$2,806.10
|
|
|
LUPRON DEPOT 11.5 MG SYRINGE
|
Facility
|
OP
|
$10,806.74
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25003851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,737.10 |
| Max. Negotiated Rate |
$10,374.47 |
| Rate for Payer: Aetna Commercial |
$8,321.19
|
| Rate for Payer: Anthem Medicaid |
$3,716.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,737.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,429.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,431.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,345.09
|
| Rate for Payer: Cash Price |
$5,403.37
|
| Rate for Payer: Cash Price |
$5,403.37
|
| Rate for Payer: Cigna Commercial |
$8,969.59
|
| Rate for Payer: First Health Commercial |
$10,266.40
|
| Rate for Payer: Humana Commercial |
$9,185.73
|
| Rate for Payer: Humana KY Medicaid |
$3,716.44
|
| Rate for Payer: Humana Medicare Advantage |
$1,737.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,754.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,861.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,975.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,791.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,509.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,105.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,645.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,401.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,456.65
|
| Rate for Payer: PHCS Commercial |
$10,374.47
|
| Rate for Payer: United Healthcare All Payer |
$9,509.93
|
|
|
LUPRON DEPOT 11.5 MG SYRINGE
|
Facility
|
IP
|
$10,806.74
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25003851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,242.02 |
| Max. Negotiated Rate |
$10,374.47 |
| Rate for Payer: Aetna Commercial |
$8,321.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,429.26
|
| Rate for Payer: Cash Price |
$5,403.37
|
| Rate for Payer: Cigna Commercial |
$8,969.59
|
| Rate for Payer: First Health Commercial |
$10,266.40
|
| Rate for Payer: Humana Commercial |
$9,185.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,861.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,975.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,242.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,509.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,105.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,645.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,401.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,456.65
|
| Rate for Payer: PHCS Commercial |
$10,374.47
|
| Rate for Payer: United Healthcare All Payer |
$9,509.93
|
|
|
LUPRON DEPOT 3.75MG KIT
|
Facility
|
OP
|
$3,602.22
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25002206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,238.80 |
| Max. Negotiated Rate |
$3,458.13 |
| Rate for Payer: Aetna Commercial |
$2,773.71
|
| Rate for Payer: Anthem Medicaid |
$1,238.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,737.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,809.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,431.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,345.09
|
| Rate for Payer: Cash Price |
$1,801.11
|
| Rate for Payer: Cash Price |
$1,801.11
|
| Rate for Payer: Cigna Commercial |
$2,989.84
|
| Rate for Payer: First Health Commercial |
$3,422.11
|
| Rate for Payer: Humana Commercial |
$3,061.89
|
| Rate for Payer: Humana KY Medicaid |
$1,238.80
|
| Rate for Payer: Humana Medicare Advantage |
$1,737.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,251.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,953.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,658.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,263.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,169.95
|
| Rate for Payer: Ohio Health Group HMO |
$2,701.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,881.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,133.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,485.53
|
| Rate for Payer: PHCS Commercial |
$3,458.13
|
| Rate for Payer: United Healthcare All Payer |
$3,169.95
|
|
|
LUPRON DEPOT 3.75MG KIT
|
Facility
|
IP
|
$3,602.22
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25002206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,080.67 |
| Max. Negotiated Rate |
$3,458.13 |
| Rate for Payer: Aetna Commercial |
$2,773.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,809.73
|
| Rate for Payer: Cash Price |
$1,801.11
|
| Rate for Payer: Cigna Commercial |
$2,989.84
|
| Rate for Payer: First Health Commercial |
$3,422.11
|
| Rate for Payer: Humana Commercial |
$3,061.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,953.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,658.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,169.95
|
| Rate for Payer: Ohio Health Group HMO |
$2,701.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,881.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,133.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,485.53
|
| Rate for Payer: PHCS Commercial |
$3,458.13
|
| Rate for Payer: United Healthcare All Payer |
$3,169.95
|
|
|
LUPRON DEPOT 7.5(22.5MG DSPSYR
|
Facility
|
OP
|
$12,877.76
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$12,362.65 |
| Rate for Payer: Aetna Commercial |
$9,915.88
|
| Rate for Payer: Anthem Medicaid |
$4,428.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,044.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$6,438.88
|
| Rate for Payer: Cash Price |
$6,438.88
|
| Rate for Payer: Cigna Commercial |
$10,688.54
|
| Rate for Payer: First Health Commercial |
$12,233.87
|
| Rate for Payer: Humana Commercial |
$10,946.10
|
| Rate for Payer: Humana KY Medicaid |
$4,428.66
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$4,473.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,559.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,503.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,517.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,332.43
|
| Rate for Payer: Ohio Health Group HMO |
$9,658.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,302.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,203.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,885.65
|
| Rate for Payer: PHCS Commercial |
$12,362.65
|
| Rate for Payer: United Healthcare All Payer |
$11,332.43
|
|
