|
MYCOSTATIN (NYSTATIN)100 15GM
|
Facility
|
OP
|
$5.87
|
|
|
Service Code
|
NDC 713067815
|
| Hospital Charge Code |
25001028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna Commercial |
$4.52
|
| Rate for Payer: Anthem Medicaid |
$2.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.58
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cigna Commercial |
$4.87
|
| Rate for Payer: First Health Commercial |
$5.58
|
| Rate for Payer: Humana Commercial |
$4.99
|
| Rate for Payer: Humana KY Medicaid |
$2.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.17
|
| Rate for Payer: Ohio Health Group HMO |
$4.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.05
|
| Rate for Payer: PHCS Commercial |
$5.64
|
| Rate for Payer: United Healthcare All Payer |
$5.17
|
|
|
MYCOSTATIN TOPICAL PWDR 1 15GM
|
Facility
|
IP
|
$6.29
|
|
|
Service Code
|
NDC 574200815
|
| Hospital Charge Code |
25001029
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.91
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.22
|
| Rate for Payer: First Health Commercial |
$5.98
|
| Rate for Payer: Humana Commercial |
$5.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.54
|
| Rate for Payer: Ohio Health Group HMO |
$4.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.34
|
| Rate for Payer: PHCS Commercial |
$6.04
|
| Rate for Payer: United Healthcare All Payer |
$5.54
|
|
|
MYCOSTATIN TOPICAL PWDR 1 15GM
|
Facility
|
OP
|
$6.29
|
|
|
Service Code
|
NDC 574200815
|
| Hospital Charge Code |
25001029
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem Medicaid |
$2.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.91
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.22
|
| Rate for Payer: First Health Commercial |
$5.98
|
| Rate for Payer: Humana Commercial |
$5.35
|
| Rate for Payer: Humana KY Medicaid |
$2.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.54
|
| Rate for Payer: Ohio Health Group HMO |
$4.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.34
|
| Rate for Payer: PHCS Commercial |
$6.04
|
| Rate for Payer: United Healthcare All Payer |
$5.54
|
|
|
MYDRIACYL (TROPICAMIDE)1% 15ML
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 24208058564
|
| Hospital Charge Code |
25003243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna Commercial |
$0.46
|
| Rate for Payer: Anthem Medicaid |
$0.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.47
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.50
|
| Rate for Payer: First Health Commercial |
$0.57
|
| Rate for Payer: Humana Commercial |
$0.51
|
| Rate for Payer: Humana KY Medicaid |
$0.21
|
| Rate for Payer: Kentucky WC Medicaid |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.53
|
| Rate for Payer: Ohio Health Group HMO |
$0.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Payer |
$0.53
|
|
|
MYDRIACYL (TROPICAMIDE)1% 15ML
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 24208058564
|
| Hospital Charge Code |
25003243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna Commercial |
$0.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.47
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.50
|
| Rate for Payer: First Health Commercial |
$0.57
|
| Rate for Payer: Humana Commercial |
$0.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.53
|
| Rate for Payer: Ohio Health Group HMO |
$0.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$0.58
|
| Rate for Payer: United Healthcare All Payer |
$0.53
|
|
|
MYELOGPHY 2/> SPINE REGIONS
|
Facility
|
OP
|
$2,622.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
32000274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,517.12 |
| Rate for Payer: Aetna Commercial |
$2,018.94
|
| Rate for Payer: Anthem Medicaid |
$901.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,045.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,311.00
|
| Rate for Payer: Cash Price |
$1,311.00
|
| Rate for Payer: Cigna Commercial |
$2,176.26
|
| Rate for Payer: First Health Commercial |
$2,490.90
|
| Rate for Payer: Humana Commercial |
$2,228.70
|
| Rate for Payer: Humana KY Medicaid |
$901.71
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$910.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,150.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,935.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$919.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,307.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,966.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,097.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,281.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,809.18
|
| Rate for Payer: PHCS Commercial |
$2,517.12
|
| Rate for Payer: United Healthcare All Payer |
$2,307.36
|
|
|
MYELOGPHY 2/> SPINE REGIONS
|
Professional
|
Both
|
$2,622.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
32000274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.32 |
| Max. Negotiated Rate |
$1,573.20 |
| Rate for Payer: Aetna Commercial |
$352.87
|
| Rate for Payer: Ambetter Exchange |
$138.42
|
| Rate for Payer: Anthem Medicaid |
$221.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$138.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$166.10
|
| Rate for Payer: Cash Price |
$1,311.00
|
| Rate for Payer: Cash Price |
$1,311.00
|
| Rate for Payer: Cigna Commercial |
$413.33
|
| Rate for Payer: Healthspan PPO |
$330.64
|
| Rate for Payer: Humana Medicaid |
$221.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$138.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$226.30
|
| Rate for Payer: Molina Healthcare Passport |
$221.86
|
| Rate for Payer: Multiplan PHCS |
$1,573.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.95
|
| Rate for Payer: UHCCP Medicaid |
$917.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$224.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.42
|
|
|
MYELOGPHY 2/> SPINE REGIONS
|
Facility
|
IP
|
$2,622.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
32000274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$786.60 |
| Max. Negotiated Rate |
$2,517.12 |
| Rate for Payer: Aetna Commercial |
$2,018.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,045.16
|
| Rate for Payer: Cash Price |
$1,311.00
|
| Rate for Payer: Cigna Commercial |
$2,176.26
|
| Rate for Payer: First Health Commercial |
$2,490.90
|
| Rate for Payer: Humana Commercial |
$2,228.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,150.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,935.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$786.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,307.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,966.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,097.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,281.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,809.18
|
| Rate for Payer: PHCS Commercial |
$2,517.12
|
| Rate for Payer: United Healthcare All Payer |
$2,307.36
|
|
|
MYELOGPHY 2/> SPINE REGIONS(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
320P0274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$413.33 |
| Rate for Payer: Aetna Commercial |
$352.87
|
| Rate for Payer: Ambetter Exchange |
$138.42
|
| Rate for Payer: Anthem Medicaid |
$221.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$138.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$138.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$166.10
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$413.33
|
| Rate for Payer: Healthspan PPO |
$330.64
|
| Rate for Payer: Humana Medicaid |
$221.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$138.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$226.30
|
| Rate for Payer: Molina Healthcare Passport |
$221.86
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.95
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$224.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$138.42
|
|
|
MYELOGPHY 2/> SPINE REGIONS(T
|
Facility
|
IP
|
$2,447.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
320T0274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$734.10 |
| Max. Negotiated Rate |
$2,349.12 |
| Rate for Payer: Aetna Commercial |
$1,884.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,908.66
|
| Rate for Payer: Cash Price |
$1,223.50
|
| Rate for Payer: Cigna Commercial |
$2,031.01
|
| Rate for Payer: First Health Commercial |
$2,324.65
|
| Rate for Payer: Humana Commercial |
$2,079.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,006.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,805.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$734.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,153.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,835.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,957.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,128.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,688.43
|
| Rate for Payer: PHCS Commercial |
$2,349.12
|
| Rate for Payer: United Healthcare All Payer |
$2,153.36
|
|
|
MYELOGPHY 2/> SPINE REGIONS(T
|
Facility
|
OP
|
$2,447.00
|
|
|
Service Code
|
HCPCS 72270
|
| Hospital Charge Code |
320T0274
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,349.12 |
| Rate for Payer: Aetna Commercial |
$1,884.19
|
| Rate for Payer: Anthem Medicaid |
$841.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,908.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,223.50
|
| Rate for Payer: Cash Price |
$1,223.50
|
| Rate for Payer: Cigna Commercial |
$2,031.01
|
| Rate for Payer: First Health Commercial |
$2,324.65
|
| Rate for Payer: Humana Commercial |
$2,079.95
|
| Rate for Payer: Humana KY Medicaid |
$841.52
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$850.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,006.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,805.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$858.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,153.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,835.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,957.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,128.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,688.43
|
| Rate for Payer: PHCS Commercial |
$2,349.12
|
| Rate for Payer: United Healthcare All Payer |
$2,153.36
|
|
|
MYELOGRAM - CERVICAL
|
Facility
|
OP
|
$1,854.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
32000006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$637.59 |
| Max. Negotiated Rate |
$1,779.84 |
| Rate for Payer: Aetna Commercial |
$1,427.58
|
| Rate for Payer: Anthem Medicaid |
$637.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,446.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cigna Commercial |
$1,538.82
|
| Rate for Payer: First Health Commercial |
$1,761.30
|
| Rate for Payer: Humana Commercial |
$1,575.90
|
| Rate for Payer: Humana KY Medicaid |
$637.59
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$644.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,520.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,368.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$650.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,631.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,390.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,483.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,279.26
|
| Rate for Payer: PHCS Commercial |
$1,779.84
|
| Rate for Payer: United Healthcare All Payer |
$1,631.52
|
|
|
MYELOGRAM - CERVICAL
|
Professional
|
Both
|
$1,854.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
32000006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.31 |
| Max. Negotiated Rate |
$1,112.40 |
| Rate for Payer: Ambetter Exchange |
$111.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.31
|
| Rate for Payer: Anthem Medicaid |
$187.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.73
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cigna Commercial |
$217.90
|
| Rate for Payer: Humana Medicaid |
$187.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$160.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$191.65
|
| Rate for Payer: Molina Healthcare Passport |
$187.89
|
| Rate for Payer: Multiplan PHCS |
$1,112.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.87
|
| Rate for Payer: UHCCP Medicaid |
$103.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$189.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.44
|
|
|
MYELOGRAM - CERVICAL
|
Facility
|
IP
|
$1,854.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
32000006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$556.20 |
| Max. Negotiated Rate |
$1,779.84 |
| Rate for Payer: Aetna Commercial |
$1,427.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,446.12
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cigna Commercial |
$1,538.82
|
| Rate for Payer: First Health Commercial |
$1,761.30
|
| Rate for Payer: Humana Commercial |
$1,575.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,520.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,368.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,631.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,390.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,483.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,279.26
|
| Rate for Payer: PHCS Commercial |
$1,779.84
|
| Rate for Payer: United Healthcare All Payer |
$1,631.52
|
|
|
MYELOGRAM - CERVICAL(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
320P0006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.31 |
| Max. Negotiated Rate |
$217.90 |
| Rate for Payer: Ambetter Exchange |
$111.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.31
|
| Rate for Payer: Anthem Medicaid |
$187.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.73
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$217.90
|
| Rate for Payer: Humana Medicaid |
$187.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$160.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$191.65
|
| Rate for Payer: Molina Healthcare Passport |
$187.89
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.87
|
| Rate for Payer: UHCCP Medicaid |
$103.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$189.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.44
|
|
|
MYELOGRAM - CERVICAL(T
|
Facility
|
IP
|
$1,554.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
320T0006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$466.20 |
| Max. Negotiated Rate |
$1,491.84 |
| Rate for Payer: Aetna Commercial |
$1,196.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,212.12
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Cigna Commercial |
$1,289.82
|
| Rate for Payer: First Health Commercial |
$1,476.30
|
| Rate for Payer: Humana Commercial |
$1,320.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,274.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,146.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,367.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,165.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,351.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.26
|
| Rate for Payer: PHCS Commercial |
$1,491.84
|
| Rate for Payer: United Healthcare All Payer |
$1,367.52
|
|
|
MYELOGRAM - CERVICAL(T
|
Facility
|
OP
|
$1,554.00
|
|
|
Service Code
|
HCPCS 62302
|
| Hospital Charge Code |
320T0006
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$534.42 |
| Max. Negotiated Rate |
$1,491.84 |
| Rate for Payer: Aetna Commercial |
$1,196.58
|
| Rate for Payer: Anthem Medicaid |
$534.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,212.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Cash Price |
$777.00
|
| Rate for Payer: Cigna Commercial |
$1,289.82
|
| Rate for Payer: First Health Commercial |
$1,476.30
|
| Rate for Payer: Humana Commercial |
$1,320.90
|
| Rate for Payer: Humana KY Medicaid |
$534.42
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$539.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,274.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,146.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$545.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,367.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,165.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,351.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.26
|
| Rate for Payer: PHCS Commercial |
$1,491.84
|
| Rate for Payer: United Healthcare All Payer |
$1,367.52
|
|
|
MYELOGRAM LUMBAR/THORAC SPINE
|
Professional
|
Both
|
$2,388.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
32000009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$1,432.80 |
| Rate for Payer: Ambetter Exchange |
$114.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.82
|
| Rate for Payer: Anthem Medicaid |
$202.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.52
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Cigna Commercial |
$224.50
|
| Rate for Payer: Humana Medicaid |
$202.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$165.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$206.11
|
| Rate for Payer: Molina Healthcare Passport |
$202.07
|
| Rate for Payer: Multiplan PHCS |
$1,432.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.98
|
| Rate for Payer: UHCCP Medicaid |
$105.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$204.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.60
|
|
|
MYELOGRAM LUMBAR/THORAC SPINE
|
Facility
|
IP
|
$2,388.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
32000009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$716.40 |
| Max. Negotiated Rate |
$2,292.48 |
| Rate for Payer: Aetna Commercial |
$1,838.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,862.64
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Cigna Commercial |
$1,982.04
|
| Rate for Payer: First Health Commercial |
$2,268.60
|
| Rate for Payer: Humana Commercial |
$2,029.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,958.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,762.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$716.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,101.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,791.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,077.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,647.72
|
| Rate for Payer: PHCS Commercial |
$2,292.48
|
| Rate for Payer: United Healthcare All Payer |
$2,101.44
|
|
|
MYELOGRAM LUMBAR/THORAC SPINE
|
Facility
|
OP
|
$2,388.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
32000009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,292.48 |
| Rate for Payer: Aetna Commercial |
$1,838.76
|
| Rate for Payer: Anthem Medicaid |
$821.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,862.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Cigna Commercial |
$1,982.04
|
| Rate for Payer: First Health Commercial |
$2,268.60
|
| Rate for Payer: Humana Commercial |
$2,029.80
|
| Rate for Payer: Humana KY Medicaid |
$821.23
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$829.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,958.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,762.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$837.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,101.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,791.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,077.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,647.72
|
| Rate for Payer: PHCS Commercial |
$2,292.48
|
| Rate for Payer: United Healthcare All Payer |
$2,101.44
|
|
|
MYELOGRAM LUMBAR/THORAC SPIN(P
|
Professional
|
Both
|
$780.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
320P0009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Ambetter Exchange |
$114.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.82
|
| Rate for Payer: Anthem Medicaid |
$202.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.52
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$224.50
|
| Rate for Payer: Humana Medicaid |
$202.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$165.59
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$206.11
|
| Rate for Payer: Molina Healthcare Passport |
$202.07
|
| Rate for Payer: Multiplan PHCS |
$468.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.98
|
| Rate for Payer: UHCCP Medicaid |
$105.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$204.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.60
|
|
|
MYELOGRAM LUMBAR/THORAC SPIN(T
|
Facility
|
OP
|
$1,608.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
320T0009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$552.99 |
| Max. Negotiated Rate |
$1,543.68 |
| Rate for Payer: Aetna Commercial |
$1,238.16
|
| Rate for Payer: Anthem Medicaid |
$552.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,254.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$804.00
|
| Rate for Payer: Cash Price |
$804.00
|
| Rate for Payer: Cigna Commercial |
$1,334.64
|
| Rate for Payer: First Health Commercial |
$1,527.60
|
| Rate for Payer: Humana Commercial |
$1,366.80
|
| Rate for Payer: Humana KY Medicaid |
$552.99
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$558.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,318.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,186.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$564.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,415.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,206.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,286.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,398.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,109.52
|
| Rate for Payer: PHCS Commercial |
$1,543.68
|
| Rate for Payer: United Healthcare All Payer |
$1,415.04
|
|
|
MYELOGRAM LUMBAR/THORAC SPIN(T
|
Facility
|
IP
|
$1,608.00
|
|
|
Service Code
|
HCPCS 62305
|
| Hospital Charge Code |
320T0009
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$482.40 |
| Max. Negotiated Rate |
$1,543.68 |
| Rate for Payer: Aetna Commercial |
$1,238.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,254.24
|
| Rate for Payer: Cash Price |
$804.00
|
| Rate for Payer: Cigna Commercial |
$1,334.64
|
| Rate for Payer: First Health Commercial |
$1,527.60
|
| Rate for Payer: Humana Commercial |
$1,366.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,318.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,186.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$482.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,415.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,206.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,286.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,398.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,109.52
|
| Rate for Payer: PHCS Commercial |
$1,543.68
|
| Rate for Payer: United Healthcare All Payer |
$1,415.04
|
|
|
MYELOGRAM - LUMBOSACRAL
|
Professional
|
Both
|
$1,854.00
|
|
|
Service Code
|
HCPCS 62304
|
| Hospital Charge Code |
32000008
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$96.64 |
| Max. Negotiated Rate |
$1,112.40 |
| Rate for Payer: Ambetter Exchange |
$109.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$96.64
|
| Rate for Payer: Anthem Medicaid |
$185.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$109.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$109.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$131.82
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cigna Commercial |
$214.27
|
| Rate for Payer: Humana Medicaid |
$185.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$158.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$109.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$189.12
|
| Rate for Payer: Molina Healthcare Passport |
$185.41
|
| Rate for Payer: Multiplan PHCS |
$1,112.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$142.81
|
| Rate for Payer: UHCCP Medicaid |
$101.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$187.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$109.85
|
|
|
MYELOGRAM - LUMBOSACRAL
|
Facility
|
OP
|
$1,854.00
|
|
|
Service Code
|
HCPCS 62304
|
| Hospital Charge Code |
32000008
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$637.59 |
| Max. Negotiated Rate |
$1,779.84 |
| Rate for Payer: Aetna Commercial |
$1,427.58
|
| Rate for Payer: Anthem Medicaid |
$637.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,446.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cash Price |
$927.00
|
| Rate for Payer: Cigna Commercial |
$1,538.82
|
| Rate for Payer: First Health Commercial |
$1,761.30
|
| Rate for Payer: Humana Commercial |
$1,575.90
|
| Rate for Payer: Humana KY Medicaid |
$637.59
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$644.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,520.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,368.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$650.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,631.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,390.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,483.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,279.26
|
| Rate for Payer: PHCS Commercial |
$1,779.84
|
| Rate for Payer: United Healthcare All Payer |
$1,631.52
|
|
