|
LUTONIX DCB 7*60*130
|
Facility
|
IP
|
$9,022.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,706.75 |
| Max. Negotiated Rate |
$8,661.60 |
| Rate for Payer: Aetna Commercial |
$6,947.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,037.55
|
| Rate for Payer: Cash Price |
$4,511.25
|
| Rate for Payer: Cigna Commercial |
$7,488.68
|
| Rate for Payer: First Health Commercial |
$8,571.38
|
| Rate for Payer: Humana Commercial |
$7,669.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,398.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,658.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,706.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,939.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,766.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,218.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,849.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,225.52
|
| Rate for Payer: PHCS Commercial |
$8,661.60
|
| Rate for Payer: United Healthcare All Payer |
$7,939.80
|
|
|
LUTONIX DCB 7*60*130
|
Facility
|
OP
|
$9,022.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,706.75 |
| Max. Negotiated Rate |
$8,661.60 |
| Rate for Payer: Aetna Commercial |
$6,947.32
|
| Rate for Payer: Anthem Medicaid |
$3,102.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,037.55
|
| Rate for Payer: Cash Price |
$4,511.25
|
| Rate for Payer: Cigna Commercial |
$7,488.68
|
| Rate for Payer: First Health Commercial |
$8,571.38
|
| Rate for Payer: Humana Commercial |
$7,669.12
|
| Rate for Payer: Humana KY Medicaid |
$3,102.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,134.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,398.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,658.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,706.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,165.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,939.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,766.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,218.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,849.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,225.52
|
| Rate for Payer: PHCS Commercial |
$8,661.60
|
| Rate for Payer: United Healthcare All Payer |
$7,939.80
|
|
|
LUTONIX DCB 7*80 5F
|
Facility
|
IP
|
$7,562.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,268.75 |
| Max. Negotiated Rate |
$7,260.00 |
| Rate for Payer: Aetna Commercial |
$5,823.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,898.75
|
| Rate for Payer: Cash Price |
$3,781.25
|
| Rate for Payer: Cigna Commercial |
$6,276.88
|
| Rate for Payer: First Health Commercial |
$7,184.38
|
| Rate for Payer: Humana Commercial |
$6,428.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,201.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,581.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,268.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,655.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,671.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,050.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,579.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,218.12
|
| Rate for Payer: PHCS Commercial |
$7,260.00
|
| Rate for Payer: United Healthcare All Payer |
$6,655.00
|
|
|
LUTONIX DCB 7*80 5F
|
Facility
|
OP
|
$7,562.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,268.75 |
| Max. Negotiated Rate |
$7,260.00 |
| Rate for Payer: Aetna Commercial |
$5,823.12
|
| Rate for Payer: Anthem Medicaid |
$2,600.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,898.75
|
| Rate for Payer: Cash Price |
$3,781.25
|
| Rate for Payer: Cigna Commercial |
$6,276.88
|
| Rate for Payer: First Health Commercial |
$7,184.38
|
| Rate for Payer: Humana Commercial |
$6,428.12
|
| Rate for Payer: Humana KY Medicaid |
$2,600.74
|
| Rate for Payer: Kentucky WC Medicaid |
$2,627.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,201.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,581.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,268.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,652.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,655.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,671.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,050.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,579.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,218.12
|
| Rate for Payer: PHCS Commercial |
$7,260.00
|
| Rate for Payer: United Healthcare All Payer |
$6,655.00
|
|
|
LUVOX 25MG TABLET
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
25000929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX 25MG TABLET
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 62559015801
|
| Hospital Charge Code |
25000929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX EQUIV 50MG TABLET
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 832167111
|
| Hospital Charge Code |
25000930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LUVOX EQUIV 50MG TABLET
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 832167111
|
| Hospital Charge Code |
25000930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
LWR XTR FSCL PLN BLK UNI NJX
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
HCPCS 64473
|
| Hospital Charge Code |
76103024
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$96.44 |
| Rate for Payer: Ambetter Exchange |
$56.23
|
| Rate for Payer: Anthem Medicaid |
$94.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.48
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Humana Medicaid |
$94.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.44
|
| Rate for Payer: Molina Healthcare Passport |
$94.55
|
| Rate for Payer: Multiplan PHCS |
$84.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.10
|
| Rate for Payer: UHCCP Medicaid |
$49.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.23
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$50.70 |
| Max. Negotiated Rate |
$162.24 |
| Rate for Payer: Aetna Commercial |
$130.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$135.71
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cigna Commercial |
$140.27
|
| Rate for Payer: First Health Commercial |
$160.55
|
| Rate for Payer: Humana Commercial |
$143.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.72
|
| Rate for Payer: Ohio Health Group HMO |
$126.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.61
|
| Rate for Payer: PHCS Commercial |
$162.24
|
| Rate for Payer: United Healthcare All Payer |
$148.72
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Professional
|
Both
|
$169.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$101.40 |
| Rate for Payer: Aetna Commercial |
$19.11
|
| Rate for Payer: Ambetter Exchange |
$17.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$17.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$17.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.44
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cigna Commercial |
$15.10
|
| Rate for Payer: Healthspan PPO |
$17.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$17.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.03
|
| Rate for Payer: Multiplan PHCS |
$101.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$22.14
|
| Rate for Payer: UHCCP Medicaid |
$59.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$17.03
|
|
|
LYME DIS. SEROLOGY EVAL.
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
HCPCS 86618
|
| Hospital Charge Code |
30001123
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$162.24 |
| Rate for Payer: Aetna Commercial |
$130.13
|
| Rate for Payer: Anthem Medicaid |
$17.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$135.71
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$17.03
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Cigna Commercial |
$140.27
|
| Rate for Payer: First Health Commercial |
$160.55
|
| Rate for Payer: Humana Commercial |
$143.65
|
| Rate for Payer: Humana KY Medicaid |
$17.03
|
| Rate for Payer: Humana Medicare Advantage |
$17.03
|
| Rate for Payer: Kentucky WC Medicaid |
$17.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.72
|
| Rate for Payer: Ohio Health Group HMO |
$126.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.61
|
| Rate for Payer: PHCS Commercial |
$162.24
|
| Rate for Payer: United Healthcare All Payer |
$148.72
|
|
|
LYMPHAZURIN1% 10MG/ML 5ML VIAL
|
Facility
|
OP
|
$2,810.89
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$2,698.45 |
| Rate for Payer: Aetna Commercial |
$2,164.39
|
| Rate for Payer: Anthem Medicaid |
$966.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,192.49
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.61
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cigna Commercial |
$2,333.04
|
| Rate for Payer: First Health Commercial |
$2,670.35
|
| Rate for Payer: Humana Commercial |
$2,389.26
|
| Rate for Payer: Humana KY Medicaid |
$966.67
|
| Rate for Payer: Humana Medicare Advantage |
$7.86
|
| Rate for Payer: Kentucky WC Medicaid |
$976.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,304.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,074.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$986.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,473.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,108.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,248.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,445.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,939.51
|
| Rate for Payer: PHCS Commercial |
$2,698.45
|
| Rate for Payer: United Healthcare All Payer |
$2,473.58
|
|
|
LYMPHAZURIN1% 10MG/ML 5ML VIAL
|
Facility
|
IP
|
$2,810.89
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$843.27 |
| Max. Negotiated Rate |
$2,698.45 |
| Rate for Payer: Aetna Commercial |
$2,164.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,192.49
|
| Rate for Payer: Cash Price |
$1,405.44
|
| Rate for Payer: Cigna Commercial |
$2,333.04
|
| Rate for Payer: First Health Commercial |
$2,670.35
|
| Rate for Payer: Humana Commercial |
$2,389.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,304.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,074.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$843.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,473.58
|
| Rate for Payer: Ohio Health Group HMO |
$2,108.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,248.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,445.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,939.51
|
| Rate for Payer: PHCS Commercial |
$2,698.45
|
| Rate for Payer: United Healthcare All Payer |
$2,473.58
|
|
|
LYMPH NODE MBI IMAGING
|
Facility
|
IP
|
$1,715.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$514.50 |
| Max. Negotiated Rate |
$1,646.40 |
| Rate for Payer: Aetna Commercial |
$1,320.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.70
|
| Rate for Payer: Cash Price |
$857.50
|
| Rate for Payer: Cigna Commercial |
$1,423.45
|
| Rate for Payer: First Health Commercial |
$1,629.25
|
| Rate for Payer: Humana Commercial |
$1,457.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,406.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,509.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,286.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,372.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,183.35
|
| Rate for Payer: PHCS Commercial |
$1,646.40
|
| Rate for Payer: United Healthcare All Payer |
$1,509.20
|
|
|
LYMPH NODE MBI IMAGING
|
Facility
|
OP
|
$1,715.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$497.35 |
| Max. Negotiated Rate |
$1,646.40 |
| Rate for Payer: Aetna Commercial |
$1,320.55
|
| Rate for Payer: Anthem Medicaid |
$589.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$857.50
|
| Rate for Payer: Cash Price |
$857.50
|
| Rate for Payer: Cigna Commercial |
$1,423.45
|
| Rate for Payer: First Health Commercial |
$1,629.25
|
| Rate for Payer: Humana Commercial |
$1,457.75
|
| Rate for Payer: Humana KY Medicaid |
$589.79
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$595.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,406.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$601.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,509.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,286.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,372.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,183.35
|
| Rate for Payer: PHCS Commercial |
$1,646.40
|
| Rate for Payer: United Healthcare All Payer |
$1,509.20
|
|
|
LYMPH NODE MBI IMAGING
|
Professional
|
Both
|
$1,715.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
34000005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$67.34 |
| Max. Negotiated Rate |
$1,029.00 |
| Rate for Payer: Aetna Commercial |
$491.15
|
| Rate for Payer: Ambetter Exchange |
$284.09
|
| Rate for Payer: Anthem Medicaid |
$140.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.91
|
| Rate for Payer: Cash Price |
$857.50
|
| Rate for Payer: Cash Price |
$857.50
|
| Rate for Payer: Cigna Commercial |
$377.41
|
| Rate for Payer: Healthspan PPO |
$490.90
|
| Rate for Payer: Humana Medicaid |
$140.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$143.29
|
| Rate for Payer: Molina Healthcare Passport |
$140.48
|
| Rate for Payer: Multiplan PHCS |
$1,029.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.32
|
| Rate for Payer: UHCCP Medicaid |
$600.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$141.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.09
|
|
|
LYMPH NODE MBI IMAGING(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340P0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna Commercial |
$491.15
|
| Rate for Payer: Ambetter Exchange |
$284.09
|
| Rate for Payer: Anthem Medicaid |
$140.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.91
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$377.41
|
| Rate for Payer: Healthspan PPO |
$490.90
|
| Rate for Payer: Humana Medicaid |
$140.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$143.29
|
| Rate for Payer: Molina Healthcare Passport |
$140.48
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.32
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$141.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.09
|
|
|
LYMPH NODE MBI IMAGING(T
|
Facility
|
IP
|
$1,540.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340T0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$462.00 |
| Max. Negotiated Rate |
$1,478.40 |
| Rate for Payer: Aetna Commercial |
$1,185.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,201.20
|
| Rate for Payer: Cash Price |
$770.00
|
| Rate for Payer: Cigna Commercial |
$1,278.20
|
| Rate for Payer: First Health Commercial |
$1,463.00
|
| Rate for Payer: Humana Commercial |
$1,309.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,262.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,136.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,355.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,155.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,339.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.60
|
| Rate for Payer: PHCS Commercial |
$1,478.40
|
| Rate for Payer: United Healthcare All Payer |
$1,355.20
|
|
|
LYMPH NODE MBI IMAGING(T
|
Facility
|
OP
|
$1,540.00
|
|
|
Service Code
|
HCPCS 78195
|
| Hospital Charge Code |
340T0005
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$497.35 |
| Max. Negotiated Rate |
$1,478.40 |
| Rate for Payer: Aetna Commercial |
$1,185.80
|
| Rate for Payer: Anthem Medicaid |
$529.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$497.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,201.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$696.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$671.42
|
| Rate for Payer: Cash Price |
$770.00
|
| Rate for Payer: Cash Price |
$770.00
|
| Rate for Payer: Cigna Commercial |
$1,278.20
|
| Rate for Payer: First Health Commercial |
$1,463.00
|
| Rate for Payer: Humana Commercial |
$1,309.00
|
| Rate for Payer: Humana KY Medicaid |
$529.61
|
| Rate for Payer: Humana Medicare Advantage |
$497.35
|
| Rate for Payer: Kentucky WC Medicaid |
$535.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,262.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,136.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$596.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,355.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,155.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,339.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.60
|
| Rate for Payer: PHCS Commercial |
$1,478.40
|
| Rate for Payer: United Healthcare All Payer |
$1,355.20
|
|
|
LYRICA 100MG CAPSULE
|
Facility
|
OP
|
$61.35
|
|
|
Service Code
|
NDC 60687050601
|
| Hospital Charge Code |
25000934
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$47.24
|
| Rate for Payer: Anthem Medicaid |
$21.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.85
|
| Rate for Payer: Cash Price |
$30.68
|
| Rate for Payer: Cigna Commercial |
$50.92
|
| Rate for Payer: First Health Commercial |
$58.28
|
| Rate for Payer: Humana Commercial |
$52.15
|
| Rate for Payer: Humana KY Medicaid |
$21.10
|
| Rate for Payer: Kentucky WC Medicaid |
$21.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.99
|
| Rate for Payer: Ohio Health Group HMO |
$46.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.33
|
| Rate for Payer: PHCS Commercial |
$58.90
|
| Rate for Payer: United Healthcare All Payer |
$53.99
|
|
|
LYRICA 100MG CAPSULE
|
Facility
|
IP
|
$61.35
|
|
|
Service Code
|
NDC 60687050601
|
| Hospital Charge Code |
25000934
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$47.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.85
|
| Rate for Payer: Cash Price |
$30.68
|
| Rate for Payer: Cigna Commercial |
$50.92
|
| Rate for Payer: First Health Commercial |
$58.28
|
| Rate for Payer: Humana Commercial |
$52.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.99
|
| Rate for Payer: Ohio Health Group HMO |
$46.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.33
|
| Rate for Payer: PHCS Commercial |
$58.90
|
| Rate for Payer: United Healthcare All Payer |
$53.99
|
|
|
LYRICA (PREGABALIN) 25MG CAP
|
Facility
|
OP
|
$61.35
|
|
|
Service Code
|
NDC 60687047301
|
| Hospital Charge Code |
25000931
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$47.24
|
| Rate for Payer: Anthem Medicaid |
$21.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.85
|
| Rate for Payer: Cash Price |
$30.68
|
| Rate for Payer: Cigna Commercial |
$50.92
|
| Rate for Payer: First Health Commercial |
$58.28
|
| Rate for Payer: Humana Commercial |
$52.15
|
| Rate for Payer: Humana KY Medicaid |
$21.10
|
| Rate for Payer: Kentucky WC Medicaid |
$21.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.99
|
| Rate for Payer: Ohio Health Group HMO |
$46.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.33
|
| Rate for Payer: PHCS Commercial |
$58.90
|
| Rate for Payer: United Healthcare All Payer |
$53.99
|
|
|
LYRICA (PREGABALIN) 25MG CAP
|
Facility
|
IP
|
$61.35
|
|
|
Service Code
|
NDC 60687047301
|
| Hospital Charge Code |
25000931
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$47.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.85
|
| Rate for Payer: Cash Price |
$30.68
|
| Rate for Payer: Cigna Commercial |
$50.92
|
| Rate for Payer: First Health Commercial |
$58.28
|
| Rate for Payer: Humana Commercial |
$52.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.99
|
| Rate for Payer: Ohio Health Group HMO |
$46.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.33
|
| Rate for Payer: PHCS Commercial |
$58.90
|
| Rate for Payer: United Healthcare All Payer |
$53.99
|
|
|
LYRICA (PREGABALIN) 50MG CAP
|
Facility
|
OP
|
$61.35
|
|
|
Service Code
|
NDC 60687048401
|
| Hospital Charge Code |
25000932
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$58.90 |
| Rate for Payer: Aetna Commercial |
$47.24
|
| Rate for Payer: Anthem Medicaid |
$21.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.85
|
| Rate for Payer: Cash Price |
$30.68
|
| Rate for Payer: Cigna Commercial |
$50.92
|
| Rate for Payer: First Health Commercial |
$58.28
|
| Rate for Payer: Humana Commercial |
$52.15
|
| Rate for Payer: Humana KY Medicaid |
$21.10
|
| Rate for Payer: Kentucky WC Medicaid |
$21.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.99
|
| Rate for Payer: Ohio Health Group HMO |
$46.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.33
|
| Rate for Payer: PHCS Commercial |
$58.90
|
| Rate for Payer: United Healthcare All Payer |
$53.99
|
|
