|
MYELOGRAPHY THORACIC SPINE(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320P0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$282.61 |
| Rate for Payer: Aetna Commercial |
$223.04
|
| Rate for Payer: Ambetter Exchange |
$96.52
|
| Rate for Payer: Anthem Medicaid |
$156.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$96.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.82
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$282.61
|
| Rate for Payer: Healthspan PPO |
$209.00
|
| Rate for Payer: Humana Medicaid |
$156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$96.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.38
|
| Rate for Payer: Molina Healthcare Passport |
$156.25
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$125.48
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$96.52
|
|
|
MYELOGRAPHY THORACIC SPINE(T
|
Facility
|
IP
|
$2,311.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320T0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$693.30 |
| Max. Negotiated Rate |
$2,218.56 |
| Rate for Payer: Aetna Commercial |
$1,779.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,802.58
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cigna Commercial |
$1,918.13
|
| Rate for Payer: First Health Commercial |
$2,195.45
|
| Rate for Payer: Humana Commercial |
$1,964.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,895.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,705.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$693.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,033.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,733.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,594.59
|
| Rate for Payer: PHCS Commercial |
$2,218.56
|
| Rate for Payer: United Healthcare All Payer |
$2,033.68
|
|
|
MYELOGRAPHY THORACIC SPINE(T
|
Facility
|
OP
|
$2,311.00
|
|
|
Service Code
|
HCPCS 72255
|
| Hospital Charge Code |
320T0272
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$730.00 |
| Max. Negotiated Rate |
$2,218.56 |
| Rate for Payer: Aetna Commercial |
$1,779.47
|
| Rate for Payer: Anthem Medicaid |
$794.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,802.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,022.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$985.50
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cash Price |
$1,155.50
|
| Rate for Payer: Cigna Commercial |
$1,918.13
|
| Rate for Payer: First Health Commercial |
$2,195.45
|
| Rate for Payer: Humana Commercial |
$1,964.35
|
| Rate for Payer: Humana KY Medicaid |
$794.75
|
| Rate for Payer: Humana Medicare Advantage |
$730.00
|
| Rate for Payer: Kentucky WC Medicaid |
$802.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,895.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,705.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$876.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$810.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,033.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,733.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,848.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,010.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,594.59
|
| Rate for Payer: PHCS Commercial |
$2,218.56
|
| Rate for Payer: United Healthcare All Payer |
$2,033.68
|
|
|
MYFORTIC 180MG [360MG TAB DR]
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
MYFORTIC 180MG [360MG TAB DR]
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
MYFORTIC 180MG TABLET DR
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.40
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna Commercial |
$10.00
|
| Rate for Payer: First Health Commercial |
$11.45
|
| Rate for Payer: Humana Commercial |
$10.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.60
|
| Rate for Payer: Ohio Health Group HMO |
$9.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.31
|
| Rate for Payer: PHCS Commercial |
$11.57
|
| Rate for Payer: United Healthcare All Payer |
$10.60
|
|
|
MYFORTIC 180MG TABLET DR
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
HCPCS J7518
|
| Hospital Charge Code |
25002507
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$9.28
|
| Rate for Payer: Anthem Medicaid |
$4.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.40
|
| Rate for Payer: Cash Price |
$6.03
|
| Rate for Payer: Cigna Commercial |
$10.00
|
| Rate for Payer: First Health Commercial |
$11.45
|
| Rate for Payer: Humana Commercial |
$10.24
|
| Rate for Payer: Humana KY Medicaid |
$4.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.60
|
| Rate for Payer: Ohio Health Group HMO |
$9.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.31
|
| Rate for Payer: PHCS Commercial |
$11.57
|
| Rate for Payer: United Healthcare All Payer |
$10.60
|
|
|
MYHERO PROBIOTIC REPLENISH LOT
|
Professional
|
Both
|
$115.00
|
|
| Hospital Charge Code |
22200119
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$40.25 |
| Max. Negotiated Rate |
$80.50 |
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.50
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
|
|
MYHERO PROBIOTIC REPLENISH LOT
|
Facility
|
OP
|
$115.00
|
|
| Hospital Charge Code |
22200119
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$34.50 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem Medicaid |
$39.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Humana KY Medicaid |
$39.55
|
| Rate for Payer: Kentucky WC Medicaid |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.35
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
MYHERO PROBIOTIC REPLENISH LOT
|
Facility
|
IP
|
$115.00
|
|
| Hospital Charge Code |
22200119
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$34.50 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.35
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
MYLANTA GAS(SIMETH)8 80MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
25001031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
MYLANTA GAS(SIMETH)8 80MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 77333081210
|
| Hospital Charge Code |
25001031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
MYLOTARG (GEMTUZUMAB) 5MG VIAL
|
Facility
|
IP
|
$55,566.46
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
25003694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16,669.94 |
| Max. Negotiated Rate |
$53,343.80 |
| Rate for Payer: Aetna Commercial |
$42,786.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43,341.84
|
| Rate for Payer: Cash Price |
$27,783.23
|
| Rate for Payer: Cigna Commercial |
$46,120.16
|
| Rate for Payer: First Health Commercial |
$52,788.14
|
| Rate for Payer: Humana Commercial |
$47,231.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45,564.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$41,008.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,669.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$48,898.48
|
| Rate for Payer: Ohio Health Group HMO |
$41,674.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44,453.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48,342.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38,340.86
|
| Rate for Payer: PHCS Commercial |
$53,343.80
|
| Rate for Payer: United Healthcare All Payer |
$48,898.48
|
|
|
MYLOTARG (GEMTUZUMAB) 5MG VIAL
|
Facility
|
OP
|
$55,566.46
|
|
|
Service Code
|
HCPCS J9203
|
| Hospital Charge Code |
25003694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.62 |
| Max. Negotiated Rate |
$53,343.80 |
| Rate for Payer: Aetna Commercial |
$42,786.17
|
| Rate for Payer: Anthem Medicaid |
$19,109.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$236.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43,341.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$331.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.44
|
| Rate for Payer: Cash Price |
$27,783.23
|
| Rate for Payer: Cash Price |
$27,783.23
|
| Rate for Payer: Cigna Commercial |
$46,120.16
|
| Rate for Payer: First Health Commercial |
$52,788.14
|
| Rate for Payer: Humana Commercial |
$47,231.49
|
| Rate for Payer: Humana KY Medicaid |
$19,109.31
|
| Rate for Payer: Humana Medicare Advantage |
$236.62
|
| Rate for Payer: Kentucky WC Medicaid |
$19,303.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45,564.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$41,008.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$283.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,492.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$48,898.48
|
| Rate for Payer: Ohio Health Group HMO |
$41,674.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44,453.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48,342.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38,340.86
|
| Rate for Payer: PHCS Commercial |
$53,343.80
|
| Rate for Payer: United Healthcare All Payer |
$48,898.48
|
|
|
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 |
$1,395.00 |
| 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 |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,045.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,208.50
|
| 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
|
$4,650.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
404T0015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,599.13 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,802.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,523.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,433.00
|
| 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 |
$1,599.13
|
| Rate for Payer: Humana Medicare Advantage |
$1,802.22
|
| 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 |
$2,162.66
|
| 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 |
$3,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,045.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,208.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
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 |
$217.00 |
| 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
|
Facility
|
OP
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,705.74 |
| 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 |
$1,802.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,523.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,433.00
|
| 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 |
$1,802.22
|
| 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 |
$2,162.66
|
| 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 |
$3,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,315.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.40
|
| 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 |
$1,488.00 |
| 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 |
$3,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,315.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.40
|
| 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
|
$4,960.00
|
|
|
Service Code
|
HCPCS 78433
|
| Hospital Charge Code |
40400015
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$122.62 |
| Max. Negotiated Rate |
$3,472.00 |
| 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 RST&STRS CT
|
Facility
|
IP
|
$4,472.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
404T0003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,341.60 |
| Max. Negotiated Rate |
$4,293.12 |
| Rate for Payer: Aetna Commercial |
$3,443.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,488.16
|
| Rate for Payer: Cash Price |
$2,236.00
|
| Rate for Payer: Cigna Commercial |
$3,711.76
|
| Rate for Payer: First Health Commercial |
$4,248.40
|
| Rate for Payer: Humana Commercial |
$3,801.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,667.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,300.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,341.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,935.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,354.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,890.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,085.68
|
| Rate for Payer: PHCS Commercial |
$4,293.12
|
| Rate for Payer: United Healthcare All Payer |
$3,935.36
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
IP
|
$4,762.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
40400003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,428.60 |
| Max. Negotiated Rate |
$4,571.52 |
| Rate for Payer: Aetna Commercial |
$3,666.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.36
|
| Rate for Payer: Cash Price |
$2,381.00
|
| Rate for Payer: Cigna Commercial |
$3,952.46
|
| Rate for Payer: First Health Commercial |
$4,523.90
|
| Rate for Payer: Humana Commercial |
$4,047.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.78
|
| Rate for Payer: PHCS Commercial |
$4,571.52
|
| Rate for Payer: United Healthcare All Payer |
$4,190.56
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Facility
|
OP
|
$4,472.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
404T0003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,537.92 |
| Max. Negotiated Rate |
$4,293.12 |
| Rate for Payer: Aetna Commercial |
$3,443.44
|
| Rate for Payer: Anthem Medicaid |
$1,537.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,079.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,488.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,911.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,807.22
|
| Rate for Payer: Cash Price |
$2,236.00
|
| Rate for Payer: Cash Price |
$2,236.00
|
| Rate for Payer: Cigna Commercial |
$3,711.76
|
| Rate for Payer: First Health Commercial |
$4,248.40
|
| Rate for Payer: Humana Commercial |
$3,801.20
|
| Rate for Payer: Humana KY Medicaid |
$1,537.92
|
| Rate for Payer: Humana Medicare Advantage |
$2,079.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,553.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,667.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,300.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,495.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,568.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,935.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,354.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,890.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,085.68
|
| Rate for Payer: PHCS Commercial |
$4,293.12
|
| Rate for Payer: United Healthcare All Payer |
$3,935.36
|
|
|
MYOCRD IMG PET RST&STRS CT
|
Professional
|
Both
|
$4,762.00
|
|
|
Service Code
|
HCPCS 78431
|
| Hospital Charge Code |
40400003
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$105.19 |
| Max. Negotiated Rate |
$3,333.40 |
| Rate for Payer: Cash Price |
$2,381.00
|
| Rate for Payer: Cash Price |
$2,381.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$105.19
|
| Rate for Payer: Multiplan PHCS |
$2,857.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,333.40
|
| Rate for Payer: UHCCP Medicaid |
$1,666.70
|
|
|
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 |
$203.00 |
| 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
|
|
