|
LYRICA (PREGABALIN) 50MG CAP
|
Facility
|
IP
|
$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 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) 75 MG CAP
|
Facility
|
OP
|
$61.35
|
|
|
Service Code
|
NDC 60687049501
|
| Hospital Charge Code |
25000933
|
|
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) 75 MG CAP
|
Facility
|
IP
|
$61.35
|
|
|
Service Code
|
NDC 60687049501
|
| Hospital Charge Code |
25000933
|
|
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
|
|
|
LYSE CHEST FIBRIN INIT DAY
|
Facility
|
IP
|
$1,911.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
76101205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$573.30 |
| Max. Negotiated Rate |
$1,834.56 |
| Rate for Payer: Aetna Commercial |
$1,471.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,490.58
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cigna Commercial |
$1,586.13
|
| Rate for Payer: First Health Commercial |
$1,815.45
|
| Rate for Payer: Humana Commercial |
$1,624.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,567.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,410.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,681.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,433.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,528.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,318.59
|
| Rate for Payer: PHCS Commercial |
$1,834.56
|
| Rate for Payer: United Healthcare All Payer |
$1,681.68
|
|
|
LYSE CHEST FIBRIN INIT DAY
|
Professional
|
Both
|
$1,911.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
76101205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$1,146.60 |
| Rate for Payer: Aetna Commercial |
$124.82
|
| Rate for Payer: Ambetter Exchange |
$63.27
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.61
|
| Rate for Payer: Anthem Medicaid |
$69.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.92
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cigna Commercial |
$162.62
|
| Rate for Payer: Healthspan PPO |
$98.35
|
| Rate for Payer: Humana Medicaid |
$69.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$97.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.38
|
| Rate for Payer: Molina Healthcare Passport |
$69.98
|
| Rate for Payer: Multiplan PHCS |
$1,146.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.25
|
| Rate for Payer: UHCCP Medicaid |
$36.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.27
|
|
|
LYSE CHEST FIBRIN INIT DAY
|
Facility
|
OP
|
$1,911.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
76101205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,834.56 |
| Rate for Payer: Aetna Commercial |
$1,471.47
|
| Rate for Payer: Anthem Medicaid |
$657.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,490.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cigna Commercial |
$1,586.13
|
| Rate for Payer: First Health Commercial |
$1,815.45
|
| Rate for Payer: Humana Commercial |
$1,624.35
|
| Rate for Payer: Humana KY Medicaid |
$657.19
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Kentucky WC Medicaid |
$663.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,567.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,410.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$670.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,681.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,433.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,528.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,318.59
|
| Rate for Payer: PHCS Commercial |
$1,834.56
|
| Rate for Payer: United Healthcare All Payer |
$1,681.68
|
|
|
LYSE CHEST FIBRIN INIT DAY(P
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
761P1205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.61 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$124.82
|
| Rate for Payer: Ambetter Exchange |
$63.27
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.61
|
| Rate for Payer: Anthem Medicaid |
$69.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.92
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$162.62
|
| Rate for Payer: Healthspan PPO |
$98.35
|
| Rate for Payer: Humana Medicaid |
$69.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$97.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.38
|
| Rate for Payer: Molina Healthcare Passport |
$69.98
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.25
|
| Rate for Payer: UHCCP Medicaid |
$36.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.27
|
|
|
LYSE CHEST FIBRIN INIT DAY(T
|
Facility
|
OP
|
$1,586.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
761T1205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$545.43 |
| Max. Negotiated Rate |
$1,522.56 |
| Rate for Payer: Aetna Commercial |
$1,221.22
|
| Rate for Payer: Anthem Medicaid |
$545.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,237.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$793.00
|
| Rate for Payer: Cash Price |
$793.00
|
| Rate for Payer: Cigna Commercial |
$1,316.38
|
| Rate for Payer: First Health Commercial |
$1,506.70
|
| Rate for Payer: Humana Commercial |
$1,348.10
|
| Rate for Payer: Humana KY Medicaid |
$545.43
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Kentucky WC Medicaid |
$550.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,300.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,170.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$556.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,395.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,189.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,379.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.34
|
| Rate for Payer: PHCS Commercial |
$1,522.56
|
| Rate for Payer: United Healthcare All Payer |
$1,395.68
|
|
|
LYSE CHEST FIBRIN INIT DAY(T
|
Facility
|
IP
|
$1,586.00
|
|
|
Service Code
|
HCPCS 32561
|
| Hospital Charge Code |
761T1205
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$475.80 |
| Max. Negotiated Rate |
$1,522.56 |
| Rate for Payer: Aetna Commercial |
$1,221.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,237.08
|
| Rate for Payer: Cash Price |
$793.00
|
| Rate for Payer: Cigna Commercial |
$1,316.38
|
| Rate for Payer: First Health Commercial |
$1,506.70
|
| Rate for Payer: Humana Commercial |
$1,348.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,300.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,170.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$475.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,395.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,189.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,379.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.34
|
| Rate for Payer: PHCS Commercial |
$1,522.56
|
| Rate for Payer: United Healthcare All Payer |
$1,395.68
|
|
|
LYSE CHEST FIBRIN SUBQ DAY
|
Professional
|
Both
|
$1,491.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
76101206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$894.60 |
| Rate for Payer: Aetna Commercial |
$111.68
|
| Rate for Payer: Ambetter Exchange |
$56.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.28
|
| Rate for Payer: Anthem Medicaid |
$62.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.49
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$144.56
|
| Rate for Payer: Healthspan PPO |
$87.43
|
| Rate for Payer: Humana Medicaid |
$62.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.46
|
| Rate for Payer: Molina Healthcare Passport |
$62.22
|
| Rate for Payer: Multiplan PHCS |
$894.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.11
|
| Rate for Payer: UHCCP Medicaid |
$31.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.24
|
|
|
LYSE CHEST FIBRIN SUBQ DAY
|
Facility
|
OP
|
$1,491.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
76101206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$512.75 |
| Max. Negotiated Rate |
$1,431.36 |
| Rate for Payer: Aetna Commercial |
$1,148.07
|
| Rate for Payer: Anthem Medicaid |
$512.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,162.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$1,237.53
|
| Rate for Payer: First Health Commercial |
$1,416.45
|
| Rate for Payer: Humana Commercial |
$1,267.35
|
| Rate for Payer: Humana KY Medicaid |
$512.75
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Kentucky WC Medicaid |
$517.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,222.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,100.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$523.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,312.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,118.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,192.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,297.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,028.79
|
| Rate for Payer: PHCS Commercial |
$1,431.36
|
| Rate for Payer: United Healthcare All Payer |
$1,312.08
|
|
|
LYSE CHEST FIBRIN SUBQ DAY
|
Facility
|
IP
|
$1,491.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
76101206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$447.30 |
| Max. Negotiated Rate |
$1,431.36 |
| Rate for Payer: Aetna Commercial |
$1,148.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,162.98
|
| Rate for Payer: Cash Price |
$745.50
|
| Rate for Payer: Cigna Commercial |
$1,237.53
|
| Rate for Payer: First Health Commercial |
$1,416.45
|
| Rate for Payer: Humana Commercial |
$1,267.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,222.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,100.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$447.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,312.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,118.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,192.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,297.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,028.79
|
| Rate for Payer: PHCS Commercial |
$1,431.36
|
| Rate for Payer: United Healthcare All Payer |
$1,312.08
|
|
|
LYSE CHEST FIBRIN SUBQ DAY(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
761P1206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna Commercial |
$111.68
|
| Rate for Payer: Ambetter Exchange |
$56.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.28
|
| Rate for Payer: Anthem Medicaid |
$62.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.49
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$144.56
|
| Rate for Payer: Healthspan PPO |
$87.43
|
| Rate for Payer: Humana Medicaid |
$62.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.46
|
| Rate for Payer: Molina Healthcare Passport |
$62.22
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.11
|
| Rate for Payer: UHCCP Medicaid |
$31.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.24
|
|
|
LYSE CHEST FIBRIN SUBQ DAY(T
|
Facility
|
OP
|
$1,116.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
761T1206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.79 |
| Max. Negotiated Rate |
$1,071.36 |
| Rate for Payer: Aetna Commercial |
$859.32
|
| Rate for Payer: Anthem Medicaid |
$383.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$870.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$926.28
|
| Rate for Payer: First Health Commercial |
$1,060.20
|
| Rate for Payer: Humana Commercial |
$948.60
|
| Rate for Payer: Humana KY Medicaid |
$383.79
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Kentucky WC Medicaid |
$387.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$915.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$823.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$391.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$982.08
|
| Rate for Payer: Ohio Health Group HMO |
$837.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$892.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$970.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$770.04
|
| Rate for Payer: PHCS Commercial |
$1,071.36
|
| Rate for Payer: United Healthcare All Payer |
$982.08
|
|
|
LYSE CHEST FIBRIN SUBQ DAY(T
|
Facility
|
IP
|
$1,116.00
|
|
|
Service Code
|
HCPCS 32562
|
| Hospital Charge Code |
761T1206
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$334.80 |
| Max. Negotiated Rate |
$1,071.36 |
| Rate for Payer: Aetna Commercial |
$859.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$870.48
|
| Rate for Payer: Cash Price |
$558.00
|
| Rate for Payer: Cigna Commercial |
$926.28
|
| Rate for Payer: First Health Commercial |
$1,060.20
|
| Rate for Payer: Humana Commercial |
$948.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$915.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$823.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$334.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$982.08
|
| Rate for Payer: Ohio Health Group HMO |
$837.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$892.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$970.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$770.04
|
| Rate for Payer: PHCS Commercial |
$1,071.36
|
| Rate for Payer: United Healthcare All Payer |
$982.08
|
|
|
LYSIS INTRANASAL SYNECHIA
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
HCPCS 30560
|
| Hospital Charge Code |
76101134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.72 |
| Max. Negotiated Rate |
$347.64 |
| Rate for Payer: Aetna Commercial |
$190.74
|
| Rate for Payer: Ambetter Exchange |
$138.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.21
|
| Rate for Payer: Anthem Medicaid |
$51.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$138.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$166.01
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$347.64
|
| Rate for Payer: Healthspan PPO |
$298.51
|
| Rate for Payer: Humana Medicaid |
$51.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$138.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.75
|
| Rate for Payer: Molina Healthcare Passport |
$51.72
|
| Rate for Payer: Multiplan PHCS |
$309.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.84
|
| Rate for Payer: UHCCP Medicaid |
$82.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.34
|
|
|
LYSIS INTRANASAL SYNECHIA
|
Facility
|
IP
|
$515.00
|
|
|
Service Code
|
HCPCS 30560
|
| Hospital Charge Code |
76101134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.50 |
| Max. Negotiated Rate |
$494.40 |
| Rate for Payer: Aetna Commercial |
$396.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$401.70
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$427.45
|
| Rate for Payer: First Health Commercial |
$489.25
|
| Rate for Payer: Humana Commercial |
$437.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$422.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$380.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$154.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$453.20
|
| Rate for Payer: Ohio Health Group HMO |
$386.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.35
|
| Rate for Payer: PHCS Commercial |
$494.40
|
| Rate for Payer: United Healthcare All Payer |
$453.20
|
|
|
LYSIS INTRANASAL SYNECHIA
|
Facility
|
OP
|
$515.00
|
|
|
Service Code
|
HCPCS 30560
|
| Hospital Charge Code |
76101134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.11 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$396.55
|
| Rate for Payer: Anthem Medicaid |
$177.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$401.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$427.45
|
| Rate for Payer: First Health Commercial |
$489.25
|
| Rate for Payer: Humana Commercial |
$437.75
|
| Rate for Payer: Humana KY Medicaid |
$177.11
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$178.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$422.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$380.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$180.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$453.20
|
| Rate for Payer: Ohio Health Group HMO |
$386.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.35
|
| Rate for Payer: PHCS Commercial |
$494.40
|
| Rate for Payer: United Healthcare All Payer |
$453.20
|
|
|
LYSIS INTRANASAL SYNECHIA(P
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
HCPCS 30560
|
| Hospital Charge Code |
761P1134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.72 |
| Max. Negotiated Rate |
$347.64 |
| Rate for Payer: Aetna Commercial |
$190.74
|
| Rate for Payer: Ambetter Exchange |
$138.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.21
|
| Rate for Payer: Anthem Medicaid |
$51.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$138.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$166.01
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$347.64
|
| Rate for Payer: Healthspan PPO |
$298.51
|
| Rate for Payer: Humana Medicaid |
$51.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$138.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.75
|
| Rate for Payer: Molina Healthcare Passport |
$51.72
|
| Rate for Payer: Multiplan PHCS |
$309.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.84
|
| Rate for Payer: UHCCP Medicaid |
$82.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.34
|
|
|
LYSIS OF ADHESIONS
|
Facility
|
OP
|
$2,200.00
|
|
|
Service Code
|
HCPCS 58740
|
| Hospital Charge Code |
76102257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$660.00 |
| Max. Negotiated Rate |
$2,112.00 |
| Rate for Payer: Aetna Commercial |
$1,694.00
|
| Rate for Payer: Anthem Medicaid |
$756.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,716.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cigna Commercial |
$1,826.00
|
| Rate for Payer: First Health Commercial |
$2,090.00
|
| Rate for Payer: Humana Commercial |
$1,870.00
|
| Rate for Payer: Humana KY Medicaid |
$756.58
|
| Rate for Payer: Kentucky WC Medicaid |
$764.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,804.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,623.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$660.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$771.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,936.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,650.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,914.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,518.00
|
| Rate for Payer: PHCS Commercial |
$2,112.00
|
| Rate for Payer: United Healthcare All Payer |
$1,936.00
|
|
|
LYSIS OF ADHESIONS
|
Professional
|
Both
|
$2,200.00
|
|
|
Service Code
|
HCPCS 58740
|
| Hospital Charge Code |
76102257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$381.93 |
| Max. Negotiated Rate |
$1,325.75 |
| Rate for Payer: Aetna Commercial |
$1,325.75
|
| Rate for Payer: Ambetter Exchange |
$858.33
|
| Rate for Payer: Anthem Medicaid |
$381.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$858.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$858.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,030.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cigna Commercial |
$1,294.46
|
| Rate for Payer: Healthspan PPO |
$1,283.66
|
| Rate for Payer: Humana Medicaid |
$381.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,139.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$858.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$858.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.57
|
| Rate for Payer: Molina Healthcare Passport |
$381.93
|
| Rate for Payer: Multiplan PHCS |
$1,320.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,115.83
|
| Rate for Payer: UHCCP Medicaid |
$770.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$858.33
|
|
|
LYSIS OF ADHESIONS
|
Facility
|
IP
|
$2,200.00
|
|
|
Service Code
|
HCPCS 58740
|
| Hospital Charge Code |
76102257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$660.00 |
| Max. Negotiated Rate |
$2,112.00 |
| Rate for Payer: Aetna Commercial |
$1,694.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,716.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cigna Commercial |
$1,826.00
|
| Rate for Payer: First Health Commercial |
$2,090.00
|
| Rate for Payer: Humana Commercial |
$1,870.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,804.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,623.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$660.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,936.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,650.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,914.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,518.00
|
| Rate for Payer: PHCS Commercial |
$2,112.00
|
| Rate for Payer: United Healthcare All Payer |
$1,936.00
|
|
|
LYSIS OF ADHESIONS(P
|
Professional
|
Both
|
$2,200.00
|
|
|
Service Code
|
HCPCS 58740
|
| Hospital Charge Code |
761P2257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$381.93 |
| Max. Negotiated Rate |
$1,325.75 |
| Rate for Payer: Aetna Commercial |
$1,325.75
|
| Rate for Payer: Ambetter Exchange |
$858.33
|
| Rate for Payer: Anthem Medicaid |
$381.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$858.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$858.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,030.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cash Price |
$1,100.00
|
| Rate for Payer: Cigna Commercial |
$1,294.46
|
| Rate for Payer: Healthspan PPO |
$1,283.66
|
| Rate for Payer: Humana Medicaid |
$381.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,139.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$858.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$858.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.57
|
| Rate for Payer: Molina Healthcare Passport |
$381.93
|
| Rate for Payer: Multiplan PHCS |
$1,320.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,115.83
|
| Rate for Payer: UHCCP Medicaid |
$770.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$858.33
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 56441
|
| Hospital Charge Code |
76102157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.50 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.15
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
LYSIS OF LABIAL ADHESIONS
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 56441
|
| Hospital Charge Code |
76102157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.89 |
| Max. Negotiated Rate |
$215.71 |
| Rate for Payer: Aetna Commercial |
$211.55
|
| Rate for Payer: Ambetter Exchange |
$144.91
|
| Rate for Payer: Anthem Medicaid |
$107.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$144.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$144.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$173.89
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$202.11
|
| Rate for Payer: Healthspan PPO |
$215.71
|
| Rate for Payer: Humana Medicaid |
$107.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$179.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$144.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$110.05
|
| Rate for Payer: Molina Healthcare Passport |
$107.89
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.38
|
| Rate for Payer: UHCCP Medicaid |
$117.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$144.91
|
|
