|
MYOCRD IMG PET 2RTRACER CT
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
MYOCRD IMG PET 2RTRACER CT
|
Facility
|
OP
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$644.80 |
| Max. Negotiated Rate |
$4,761.60 |
| Rate for Payer: Aetna Commercial |
$3,819.20
|
| Rate for Payer: Anthem Medicaid |
$1,705.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,770.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,478.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,389.86
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cigna Commercial |
$4,116.80
|
| Rate for Payer: First Health Commercial |
$4,712.00
|
| Rate for Payer: Humana Commercial |
$4,216.00
|
| Rate for Payer: Humana KY Medicaid |
$1,705.74
|
| Rate for Payer: Humana Medicare Advantage |
$1,770.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,723.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,067.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,124.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,739.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$644.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,537.60
|
| Rate for Payer: PHCS Commercial |
$4,761.60
|
| Rate for Payer: United Healthcare All Payer |
$4,364.80
|
|
|
MYOCRD IMG PET 2RTRACER CT
|
Facility
|
IP
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$644.80 |
| Max. Negotiated Rate |
$4,761.60 |
| Rate for Payer: Aetna Commercial |
$3,819.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cigna Commercial |
$4,116.80
|
| Rate for Payer: First Health Commercial |
$4,712.00
|
| Rate for Payer: Humana Commercial |
$4,216.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,067.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,488.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$644.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,537.60
|
| Rate for Payer: PHCS Commercial |
$4,761.60
|
| Rate for Payer: United Healthcare All Payer |
$4,364.80
|
|
|
MYOCRD IMG PET 2RTRACER CT
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404P0015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$310.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$310.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.62
|
| Rate for Payer: Multiplan PHCS |
$186.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.00
|
| Rate for Payer: UHCCP Medicaid |
$108.50
|
|
|
MYOCRD IMG PET 2RTRACER CT
|
Professional
|
Both
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$122.62 |
| Max. Negotiated Rate |
$4,960.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,960.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$122.62
|
| Rate for Payer: Multiplan PHCS |
$2,976.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,472.00
|
| Rate for Payer: UHCCP Medicaid |
$1,736.00
|
|
|
MYOCRD IMG PET 2RTRACER CT
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,770.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,478.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,389.86
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Humana Medicare Advantage |
$1,770.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,124.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
404P0003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$290.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$290.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$105.19
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.00
|
| Rate for Payer: UHCCP Medicaid |
$101.50
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
IP
|
$4,199.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
404T0003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$545.87 |
| Max. Negotiated Rate |
$4,031.04 |
| Rate for Payer: Aetna Commercial |
$3,233.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,275.22
|
| Rate for Payer: Cash Price |
$2,099.50
|
| Rate for Payer: Cigna Commercial |
$3,485.17
|
| Rate for Payer: First Health Commercial |
$3,989.05
|
| Rate for Payer: Humana Commercial |
$3,569.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,443.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,098.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,259.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,695.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$839.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$545.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,301.69
|
| Rate for Payer: PHCS Commercial |
$4,031.04
|
| Rate for Payer: United Healthcare All Payer |
$3,695.12
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
IP
|
$4,489.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
40400003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$583.57 |
| Max. Negotiated Rate |
$4,309.44 |
| Rate for Payer: Aetna Commercial |
$3,456.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,501.42
|
| Rate for Payer: Cash Price |
$2,244.50
|
| Rate for Payer: Cigna Commercial |
$3,725.87
|
| Rate for Payer: First Health Commercial |
$4,264.55
|
| Rate for Payer: Humana Commercial |
$3,815.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,680.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,312.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,346.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,950.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,366.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$897.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,391.59
|
| Rate for Payer: PHCS Commercial |
$4,309.44
|
| Rate for Payer: United Healthcare All Payer |
$3,950.32
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
OP
|
$4,489.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
40400003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$583.57 |
| Max. Negotiated Rate |
$4,309.44 |
| Rate for Payer: Aetna Commercial |
$3,456.53
|
| Rate for Payer: Anthem Medicaid |
$1,543.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,042.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,501.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,859.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,757.44
|
| Rate for Payer: Cash Price |
$2,244.50
|
| Rate for Payer: Cash Price |
$2,244.50
|
| Rate for Payer: Cigna Commercial |
$3,725.87
|
| Rate for Payer: First Health Commercial |
$4,264.55
|
| Rate for Payer: Humana Commercial |
$3,815.65
|
| Rate for Payer: Humana KY Medicaid |
$1,543.77
|
| Rate for Payer: Humana Medicare Advantage |
$2,042.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,559.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,680.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,312.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,451.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,574.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,950.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,366.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$897.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,391.59
|
| Rate for Payer: PHCS Commercial |
$4,309.44
|
| Rate for Payer: United Healthcare All Payer |
$3,950.32
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
OP
|
$4,199.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
404T0003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$545.87 |
| Max. Negotiated Rate |
$4,031.04 |
| Rate for Payer: Aetna Commercial |
$3,233.23
|
| Rate for Payer: Anthem Medicaid |
$1,444.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,042.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,275.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,859.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,757.44
|
| Rate for Payer: Cash Price |
$2,099.50
|
| Rate for Payer: Cash Price |
$2,099.50
|
| Rate for Payer: Cigna Commercial |
$3,485.17
|
| Rate for Payer: First Health Commercial |
$3,989.05
|
| Rate for Payer: Humana Commercial |
$3,569.15
|
| Rate for Payer: Humana KY Medicaid |
$1,444.04
|
| Rate for Payer: Humana Medicare Advantage |
$2,042.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,458.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,443.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,098.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,451.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,473.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,695.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$839.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$545.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,301.69
|
| Rate for Payer: PHCS Commercial |
$4,031.04
|
| Rate for Payer: United Healthcare All Payer |
$3,695.12
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Professional
|
Both
|
$4,489.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
40400003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$105.19 |
| Max. Negotiated Rate |
$4,489.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,489.00
|
| Rate for Payer: Cash Price |
$2,244.50
|
| Rate for Payer: Cash Price |
$2,244.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$105.19
|
| Rate for Payer: Multiplan PHCS |
$2,693.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,142.30
|
| Rate for Payer: UHCCP Medicaid |
$1,571.15
|
|
|
MYOFLEX(TRIETHANOLAMINE)10 2OZ
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 41167005723
|
| Hospital Charge Code |
25001034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
MYOFLEX(TRIETHANOLAMINE)10 2OZ
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 41167005723
|
| Hospital Charge Code |
25001034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
MYOMECTOMY
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58140
|
| Hospital Charge Code |
76102209
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
MYOMECTOMY
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58140
|
| Hospital Charge Code |
76102209
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
MYOMECTOMY
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58140
|
| Hospital Charge Code |
76102209
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$488.28 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,388.04
|
| Rate for Payer: Anthem Medicaid |
$488.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,349.89
|
| Rate for Payer: Healthspan PPO |
$1,343.97
|
| Rate for Payer: Humana Medicaid |
$488.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,194.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$498.05
|
| Rate for Payer: Molina Healthcare Passport |
$488.28
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$493.16
|
|
|
MYOMECTOMY(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 58140
|
| Hospital Charge Code |
761P2209
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$488.28 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,388.04
|
| Rate for Payer: Anthem Medicaid |
$488.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,349.89
|
| Rate for Payer: Healthspan PPO |
$1,343.97
|
| Rate for Payer: Humana Medicaid |
$488.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,194.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$498.05
|
| Rate for Payer: Molina Healthcare Passport |
$488.28
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$493.16
|
|
|
MYRBETRIQ 25MG TABLET (ER)
|
Facility
|
OP
|
$32.34
|
|
|
Service Code
|
NDC 469260130
|
| Hospital Charge Code |
25003244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Aetna Commercial |
$24.90
|
| Rate for Payer: Anthem Medicaid |
$11.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.23
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cigna Commercial |
$26.84
|
| Rate for Payer: First Health Commercial |
$30.72
|
| Rate for Payer: Humana Commercial |
$27.49
|
| Rate for Payer: Humana KY Medicaid |
$11.12
|
| Rate for Payer: Kentucky WC Medicaid |
$11.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.46
|
| Rate for Payer: Ohio Health Group HMO |
$24.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.03
|
| Rate for Payer: PHCS Commercial |
$31.05
|
| Rate for Payer: United Healthcare All Payer |
$28.46
|
|
|
MYRBETRIQ 25MG TABLET (ER)
|
Facility
|
IP
|
$32.34
|
|
|
Service Code
|
NDC 469260130
|
| Hospital Charge Code |
25003244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Aetna Commercial |
$24.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.23
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cigna Commercial |
$26.84
|
| Rate for Payer: First Health Commercial |
$30.72
|
| Rate for Payer: Humana Commercial |
$27.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.46
|
| Rate for Payer: Ohio Health Group HMO |
$24.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.03
|
| Rate for Payer: PHCS Commercial |
$31.05
|
| Rate for Payer: United Healthcare All Payer |
$28.46
|
|
|
MYRBETRIQ 50MG TABLET (ER)
|
Facility
|
IP
|
$32.34
|
|
|
Service Code
|
NDC 469260230
|
| Hospital Charge Code |
25003245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Aetna Commercial |
$24.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.23
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cigna Commercial |
$26.84
|
| Rate for Payer: First Health Commercial |
$30.72
|
| Rate for Payer: Humana Commercial |
$27.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.46
|
| Rate for Payer: Ohio Health Group HMO |
$24.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.03
|
| Rate for Payer: PHCS Commercial |
$31.05
|
| Rate for Payer: United Healthcare All Payer |
$28.46
|
|
|
MYRBETRIQ 50MG TABLET (ER)
|
Facility
|
OP
|
$32.34
|
|
|
Service Code
|
NDC 469260230
|
| Hospital Charge Code |
25003245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Humana Commercial |
$27.49
|
| Rate for Payer: Humana KY Medicaid |
$11.12
|
| Rate for Payer: Kentucky WC Medicaid |
$11.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$28.46
|
| Rate for Payer: Ohio Health Group HMO |
$24.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.03
|
| Rate for Payer: PHCS Commercial |
$31.05
|
| Rate for Payer: United Healthcare All Payer |
$28.46
|
| Rate for Payer: Aetna Commercial |
$24.90
|
| Rate for Payer: Anthem Medicaid |
$11.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.23
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cigna Commercial |
$26.84
|
| Rate for Payer: First Health Commercial |
$30.72
|
|
|
MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR AREA)
|
Facility
|
OP
|
$3,897.84
|
|
|
Service Code
|
CPT 69620
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,784.17 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
|
|
MYRINGOTOMY
|
Facility
|
IP
|
$2,045.00
|
|
|
Service Code
|
HCPCS 69420
|
| Hospital Charge Code |
76102417
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$265.85 |
| Max. Negotiated Rate |
$1,963.20 |
| Rate for Payer: Aetna Commercial |
$1,574.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,595.10
|
| Rate for Payer: Cash Price |
$1,022.50
|
| Rate for Payer: Cigna Commercial |
$1,697.35
|
| Rate for Payer: First Health Commercial |
$1,942.75
|
| Rate for Payer: Humana Commercial |
$1,738.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,676.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,509.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$613.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,799.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,533.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$409.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.95
|
| Rate for Payer: PHCS Commercial |
$1,963.20
|
| Rate for Payer: United Healthcare All Payer |
$1,799.60
|
|
|
MYRINGOTOMY
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS 69421
|
| Hospital Charge Code |
76102418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.26 |
| Max. Negotiated Rate |
$3,841.92 |
| Rate for Payer: Aetna Commercial |
$3,081.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,121.56
|
| Rate for Payer: Cash Price |
$2,001.00
|
| Rate for Payer: Cigna Commercial |
$3,321.66
|
| Rate for Payer: First Health Commercial |
$3,801.90
|
| Rate for Payer: Humana Commercial |
$3,401.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,281.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,953.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,521.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,001.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.62
|
| Rate for Payer: PHCS Commercial |
$3,841.92
|
| Rate for Payer: United Healthcare All Payer |
$3,521.76
|
|
