|
LUPRON DEPOT 7.5(22.5MG DSPSYR
|
Facility
|
IP
|
$12,877.76
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,863.33 |
| Max. Negotiated Rate |
$12,362.65 |
| Rate for Payer: Aetna Commercial |
$9,915.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,044.65
|
| 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: 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 |
$3,863.33
|
| 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
|
|
|
LUPRON DEPOT 7.5G DISP SYRIN
|
Facility
|
IP
|
$4,292.62
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,287.79 |
| Max. Negotiated Rate |
$4,120.92 |
| Rate for Payer: Aetna Commercial |
$3,305.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.24
|
| Rate for Payer: Cash Price |
$2,146.31
|
| Rate for Payer: Cigna Commercial |
$3,562.87
|
| Rate for Payer: First Health Commercial |
$4,077.99
|
| Rate for Payer: Humana Commercial |
$3,648.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,287.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.91
|
| Rate for Payer: PHCS Commercial |
$4,120.92
|
| Rate for Payer: United Healthcare All Payer |
$3,777.51
|
|
|
LUPRON DEPOT 7.5G DISP SYRIN
|
Facility
|
OP
|
$4,292.62
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$4,120.92 |
| Rate for Payer: Aetna Commercial |
$3,305.32
|
| Rate for Payer: Anthem Medicaid |
$1,476.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$2,146.31
|
| Rate for Payer: Cash Price |
$2,146.31
|
| Rate for Payer: Cigna Commercial |
$3,562.87
|
| Rate for Payer: First Health Commercial |
$4,077.99
|
| Rate for Payer: Humana Commercial |
$3,648.73
|
| Rate for Payer: Humana KY Medicaid |
$1,476.23
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,491.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,505.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.91
|
| Rate for Payer: PHCS Commercial |
$4,120.92
|
| Rate for Payer: United Healthcare All Payer |
$3,777.51
|
|
|
LUPRON DEPOT 7.5MG (30MG KIT)
|
Facility
|
IP
|
$17,170.40
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,151.12 |
| Max. Negotiated Rate |
$16,483.58 |
| Rate for Payer: Aetna Commercial |
$13,221.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,392.91
|
| Rate for Payer: Cash Price |
$8,585.20
|
| Rate for Payer: Cigna Commercial |
$14,251.43
|
| Rate for Payer: First Health Commercial |
$16,311.88
|
| Rate for Payer: Humana Commercial |
$14,594.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,079.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,671.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,151.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,109.95
|
| Rate for Payer: Ohio Health Group HMO |
$12,877.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,736.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,938.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,847.58
|
| Rate for Payer: PHCS Commercial |
$16,483.58
|
| Rate for Payer: United Healthcare All Payer |
$15,109.95
|
|
|
LUPRON DEPOT 7.5MG (30MG KIT)
|
Facility
|
OP
|
$17,170.40
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$16,483.58 |
| Rate for Payer: Aetna Commercial |
$13,221.21
|
| Rate for Payer: Anthem Medicaid |
$5,904.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,392.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$8,585.20
|
| Rate for Payer: Cash Price |
$8,585.20
|
| Rate for Payer: Cigna Commercial |
$14,251.43
|
| Rate for Payer: First Health Commercial |
$16,311.88
|
| Rate for Payer: Humana Commercial |
$14,594.84
|
| Rate for Payer: Humana KY Medicaid |
$5,904.90
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,965.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,079.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,671.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,023.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,109.95
|
| Rate for Payer: Ohio Health Group HMO |
$12,877.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,736.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,938.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,847.58
|
| Rate for Payer: PHCS Commercial |
$16,483.58
|
| Rate for Payer: United Healthcare All Payer |
$15,109.95
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$4,292.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$4,120.95 |
| Rate for Payer: Aetna Commercial |
$3,305.35
|
| Rate for Payer: Anthem Medicaid |
$1,476.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cigna Commercial |
$3,562.91
|
| Rate for Payer: First Health Commercial |
$4,078.03
|
| Rate for Payer: Humana Commercial |
$3,648.76
|
| Rate for Payer: Humana KY Medicaid |
$1,476.25
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,491.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,505.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.94
|
| Rate for Payer: PHCS Commercial |
$4,120.95
|
| Rate for Payer: United Healthcare All Payer |
$3,777.54
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$4,292.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$4,120.95 |
| Rate for Payer: Aetna Commercial |
$3,305.35
|
| Rate for Payer: Anthem Medicaid |
$1,476.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cigna Commercial |
$3,562.91
|
| Rate for Payer: First Health Commercial |
$4,078.03
|
| Rate for Payer: Humana Commercial |
$3,648.76
|
| Rate for Payer: Humana KY Medicaid |
$1,476.25
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,491.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,505.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.94
|
| Rate for Payer: PHCS Commercial |
$4,120.95
|
| Rate for Payer: United Healthcare All Payer |
$3,777.54
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$25,755.98
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$24,725.74 |
| Rate for Payer: Aetna Commercial |
$19,832.10
|
| Rate for Payer: Anthem Medicaid |
$8,857.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$155.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,089.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$217.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$209.82
|
| Rate for Payer: Cash Price |
$12,877.99
|
| Rate for Payer: Cash Price |
$12,877.99
|
| Rate for Payer: Cigna Commercial |
$21,377.46
|
| Rate for Payer: First Health Commercial |
$24,468.18
|
| Rate for Payer: Humana Commercial |
$21,892.58
|
| Rate for Payer: Humana KY Medicaid |
$8,857.48
|
| Rate for Payer: Humana Medicare Advantage |
$155.42
|
| Rate for Payer: Kentucky WC Medicaid |
$8,947.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,119.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,007.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,035.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,665.26
|
| Rate for Payer: Ohio Health Group HMO |
$19,316.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,604.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,407.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,771.63
|
| Rate for Payer: PHCS Commercial |
$24,725.74
|
| Rate for Payer: United Healthcare All Payer |
$22,665.26
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$25,755.98
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,726.79 |
| Max. Negotiated Rate |
$24,725.74 |
| Rate for Payer: Aetna Commercial |
$19,832.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,089.66
|
| Rate for Payer: Cash Price |
$12,877.99
|
| Rate for Payer: Cigna Commercial |
$21,377.46
|
| Rate for Payer: First Health Commercial |
$24,468.18
|
| Rate for Payer: Humana Commercial |
$21,892.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,119.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,007.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,726.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,665.26
|
| Rate for Payer: Ohio Health Group HMO |
$19,316.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,604.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,407.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,771.63
|
| Rate for Payer: PHCS Commercial |
$24,725.74
|
| Rate for Payer: United Healthcare All Payer |
$22,665.26
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$4,292.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,287.80 |
| Max. Negotiated Rate |
$4,120.95 |
| Rate for Payer: Aetna Commercial |
$3,305.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.27
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cigna Commercial |
$3,562.91
|
| Rate for Payer: First Health Commercial |
$4,078.03
|
| Rate for Payer: Humana Commercial |
$3,648.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,287.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.94
|
| Rate for Payer: PHCS Commercial |
$4,120.95
|
| Rate for Payer: United Healthcare All Payer |
$3,777.54
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Professional
|
Both
|
$4,292.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$2,575.60 |
| Rate for Payer: Aetna Commercial |
$190.26
|
| Rate for Payer: Ambetter Exchange |
$155.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$155.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.50
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$155.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.42
|
| Rate for Payer: Multiplan PHCS |
$2,575.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$202.05
|
| Rate for Payer: UHCCP Medicaid |
$1,502.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$155.42
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$4,292.66
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,287.80 |
| Max. Negotiated Rate |
$4,120.95 |
| Rate for Payer: Aetna Commercial |
$3,305.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.27
|
| Rate for Payer: Cash Price |
$2,146.33
|
| Rate for Payer: Cigna Commercial |
$3,562.91
|
| Rate for Payer: First Health Commercial |
$4,078.03
|
| Rate for Payer: Humana Commercial |
$3,648.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,519.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,167.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,287.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,777.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,434.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,734.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,961.94
|
| Rate for Payer: PHCS Commercial |
$4,120.95
|
| Rate for Payer: United Healthcare All Payer |
$3,777.54
|
|
|
LURBINECTEDIN 0.1mg (4mg SDV)
|
Facility
|
IP
|
$44,199.50
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
25003944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,259.85 |
| Max. Negotiated Rate |
$42,431.52 |
| Rate for Payer: Aetna Commercial |
$34,033.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,475.61
|
| Rate for Payer: Cash Price |
$22,099.75
|
| Rate for Payer: Cigna Commercial |
$36,685.58
|
| Rate for Payer: First Health Commercial |
$41,989.53
|
| Rate for Payer: Humana Commercial |
$37,569.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,243.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,619.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,259.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,895.56
|
| Rate for Payer: Ohio Health Group HMO |
$33,149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35,359.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38,453.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30,497.65
|
| Rate for Payer: PHCS Commercial |
$42,431.52
|
| Rate for Payer: United Healthcare All Payer |
$38,895.56
|
|
|
LURBINECTEDIN 0.1mg (4mg SDV)
|
Facility
|
OP
|
$44,199.50
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
25003944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.13 |
| Max. Negotiated Rate |
$42,431.52 |
| Rate for Payer: Aetna Commercial |
$34,033.61
|
| Rate for Payer: Anthem Medicaid |
$15,200.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$206.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,475.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$288.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$278.28
|
| Rate for Payer: Cash Price |
$22,099.75
|
| Rate for Payer: Cash Price |
$22,099.75
|
| Rate for Payer: Cigna Commercial |
$36,685.58
|
| Rate for Payer: First Health Commercial |
$41,989.53
|
| Rate for Payer: Humana Commercial |
$37,569.57
|
| Rate for Payer: Humana KY Medicaid |
$15,200.21
|
| Rate for Payer: Humana Medicare Advantage |
$206.13
|
| Rate for Payer: Kentucky WC Medicaid |
$15,354.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,243.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,619.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,505.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,895.56
|
| Rate for Payer: Ohio Health Group HMO |
$33,149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35,359.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38,453.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30,497.65
|
| Rate for Payer: PHCS Commercial |
$42,431.52
|
| Rate for Payer: United Healthcare All Payer |
$38,895.56
|
|
|
LUTEINIZING HORMONE
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$127.80 |
| Rate for Payer: Aetna Commercial |
$31.97
|
| Rate for Payer: Ambetter Exchange |
$18.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.22
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cigna Commercial |
$16.29
|
| Rate for Payer: Healthspan PPO |
$19.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.52
|
| Rate for Payer: Multiplan PHCS |
$127.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.08
|
| Rate for Payer: UHCCP Medicaid |
$74.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.52
|
|
|
LUTEINIZING HORMONE
|
Facility
|
IP
|
$213.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.90 |
| Max. Negotiated Rate |
$204.48 |
| Rate for Payer: Aetna Commercial |
$164.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.04
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cigna Commercial |
$176.79
|
| Rate for Payer: First Health Commercial |
$202.35
|
| Rate for Payer: Humana Commercial |
$181.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$174.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$157.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$187.44
|
| Rate for Payer: Ohio Health Group HMO |
$159.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.97
|
| Rate for Payer: PHCS Commercial |
$204.48
|
| Rate for Payer: United Healthcare All Payer |
$187.44
|
|
|
LUTEINIZING HORMONE
|
Facility
|
OP
|
$213.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.52 |
| Max. Negotiated Rate |
$204.48 |
| Rate for Payer: Aetna Commercial |
$164.01
|
| Rate for Payer: Anthem Medicaid |
$18.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.52
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cash Price |
$106.50
|
| Rate for Payer: Cigna Commercial |
$176.79
|
| Rate for Payer: First Health Commercial |
$202.35
|
| Rate for Payer: Humana Commercial |
$181.05
|
| Rate for Payer: Humana KY Medicaid |
$18.52
|
| Rate for Payer: Humana Medicare Advantage |
$18.52
|
| Rate for Payer: Kentucky WC Medicaid |
$18.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$174.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$157.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$187.44
|
| Rate for Payer: Ohio Health Group HMO |
$159.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$185.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.97
|
| Rate for Payer: PHCS Commercial |
$204.48
|
| Rate for Payer: United Healthcare All Payer |
$187.44
|
|
|
LUTONIX 018 DCB 4*100 4F
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
LUTONIX 018 DCB 4*100 4F
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
LUTONIX 018 DCB 4*150 4F
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
LUTONIX 018 DCB 4*150 4F
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
LUTONIX 018 DCB 4*220 4F
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
LUTONIX 018 DCB 4*220 4F
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
LUTONIX 018 DCB 4*300 4F
|
Facility
|
OP
|
$12,675.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,802.50 |
| Max. Negotiated Rate |
$12,168.00 |
| Rate for Payer: Aetna Commercial |
$9,759.75
|
| Rate for Payer: Anthem Medicaid |
$4,358.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,886.50
|
| Rate for Payer: Cash Price |
$6,337.50
|
| Rate for Payer: Cigna Commercial |
$10,520.25
|
| Rate for Payer: First Health Commercial |
$12,041.25
|
| Rate for Payer: Humana Commercial |
$10,773.75
|
| Rate for Payer: Humana KY Medicaid |
$4,358.93
|
| Rate for Payer: Kentucky WC Medicaid |
$4,403.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,393.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,354.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,802.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,446.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,154.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,027.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,745.75
|
| Rate for Payer: PHCS Commercial |
$12,168.00
|
| Rate for Payer: United Healthcare All Payer |
$11,154.00
|
|
|
LUTONIX 018 DCB 4*300 4F
|
Facility
|
IP
|
$12,675.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,802.50 |
| Max. Negotiated Rate |
$12,168.00 |
| Rate for Payer: Aetna Commercial |
$9,759.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,886.50
|
| Rate for Payer: Cash Price |
$6,337.50
|
| Rate for Payer: Cigna Commercial |
$10,520.25
|
| Rate for Payer: First Health Commercial |
$12,041.25
|
| Rate for Payer: Humana Commercial |
$10,773.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,393.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,354.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,802.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,154.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,027.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,745.75
|
| Rate for Payer: PHCS Commercial |
$12,168.00
|
| Rate for Payer: United Healthcare All Payer |
$11,154.00
|
|
