|
BREAST TOMOSYNTHESIS BILAT(T
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$120.75 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$255.89
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$120.75
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$265.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.10
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$286.35
|
| Rate for Payer: First Health Commercial |
$327.75
|
| Rate for Payer: Humana Commercial |
$293.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$254.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$303.60
|
| Rate for Payer: Ohio Health Group HMO |
$258.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$331.20
|
| Rate for Payer: United Healthcare All Payer |
$303.60
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$44.85 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$265.65
|
| Rate for Payer: Anthem Medicaid |
$118.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.10
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$286.35
|
| Rate for Payer: First Health Commercial |
$327.75
|
| Rate for Payer: Humana Commercial |
$293.25
|
| Rate for Payer: Humana KY Medicaid |
$118.65
|
| Rate for Payer: Kentucky WC Medicaid |
$119.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$254.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$121.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$303.60
|
| Rate for Payer: Ohio Health Group HMO |
$258.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$331.20
|
| Rate for Payer: United Healthcare All Payer |
$303.60
|
|
|
BREAST TOMOSYNTHESIS UNILAT(P
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
401P0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$255.89 |
| Rate for Payer: Buckeye Medicare Advantage |
$230.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$255.89
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$14.95 |
| 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 |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$14.95 |
| 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 |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
BREATH HYDROGEN/METHANE TES(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761P2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$96.10
|
| Rate for Payer: Anthem Medicaid |
$36.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$78.82
|
| Rate for Payer: Healthspan PPO |
$78.64
|
| Rate for Payer: Humana Medicaid |
$36.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.41
|
| Rate for Payer: Molina Healthcare Passport |
$36.68
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.05
|
|
|
BREATH HYDROGEN/METHANE TES(T
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761T2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BREATH HYDROGEN/METHANE TES(T
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761T2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$96.10
|
| Rate for Payer: Anthem Medicaid |
$36.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$78.82
|
| Rate for Payer: Healthspan PPO |
$78.64
|
| Rate for Payer: Humana Medicaid |
$36.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.41
|
| Rate for Payer: Molina Healthcare Passport |
$36.68
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.05
|
|
|
BRETHINE(TERBUTALIN 2.5MG/1TAB
|
Facility
|
IP
|
$12.35
|
|
|
Service Code
|
NDC 527131801
|
| Hospital Charge Code |
25000345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna Commercial |
$9.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.63
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$10.25
|
| Rate for Payer: First Health Commercial |
$11.73
|
| Rate for Payer: Humana Commercial |
$10.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.87
|
| Rate for Payer: Ohio Health Group HMO |
$9.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.83
|
| Rate for Payer: PHCS Commercial |
$11.86
|
| Rate for Payer: United Healthcare All Payer |
$10.87
|
|
|
BRETHINE(TERBUTALIN 2.5MG/1TAB
|
Facility
|
OP
|
$12.35
|
|
|
Service Code
|
NDC 527131801
|
| Hospital Charge Code |
25000345
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Aetna Commercial |
$9.51
|
| Rate for Payer: Anthem Medicaid |
$4.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.63
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cigna Commercial |
$10.25
|
| Rate for Payer: First Health Commercial |
$11.73
|
| Rate for Payer: Humana Commercial |
$10.50
|
| Rate for Payer: Humana KY Medicaid |
$4.25
|
| Rate for Payer: Kentucky WC Medicaid |
$4.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.87
|
| Rate for Payer: Ohio Health Group HMO |
$9.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.83
|
| Rate for Payer: PHCS Commercial |
$11.86
|
| Rate for Payer: United Healthcare All Payer |
$10.87
|
|
|
BRETHINE(TERBUTALINE) 1MG/1ML
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
25002383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$61.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.40
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$66.40
|
| Rate for Payer: First Health Commercial |
$76.00
|
| Rate for Payer: Humana Commercial |
$68.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.40
|
| Rate for Payer: Ohio Health Group HMO |
$60.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.80
|
| Rate for Payer: PHCS Commercial |
$76.80
|
| Rate for Payer: United Healthcare All Payer |
$70.40
|
|
|
BRETHINE(TERBUTALINE) 1MG/1ML
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS J3105
|
| Hospital Charge Code |
25002383
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$61.60
|
| Rate for Payer: Anthem Medicaid |
$27.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.40
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$66.40
|
| Rate for Payer: First Health Commercial |
$76.00
|
| Rate for Payer: Humana Commercial |
$68.00
|
| Rate for Payer: Humana KY Medicaid |
$27.51
|
| Rate for Payer: Kentucky WC Medicaid |
$27.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.40
|
| Rate for Payer: Ohio Health Group HMO |
$60.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.80
|
| Rate for Payer: PHCS Commercial |
$76.80
|
| Rate for Payer: United Healthcare All Payer |
$70.40
|
|
|
BREVITAL (METHO 500MG/50ML
|
Facility
|
OP
|
$171.98
|
|
|
Service Code
|
NDC 42023010501
|
| Hospital Charge Code |
25003855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.10 |
| Rate for Payer: Aetna Commercial |
$132.42
|
| Rate for Payer: Anthem Medicaid |
$59.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.14
|
| Rate for Payer: Cash Price |
$85.99
|
| Rate for Payer: Cigna Commercial |
$142.74
|
| Rate for Payer: First Health Commercial |
$163.38
|
| Rate for Payer: Humana Commercial |
$146.18
|
| Rate for Payer: Humana KY Medicaid |
$59.14
|
| Rate for Payer: Kentucky WC Medicaid |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.34
|
| Rate for Payer: Ohio Health Group HMO |
$128.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.31
|
| Rate for Payer: PHCS Commercial |
$165.10
|
| Rate for Payer: United Healthcare All Payer |
$151.34
|
|
|
BREVITAL (METHO 500MG/50ML
|
Facility
|
IP
|
$171.98
|
|
|
Service Code
|
NDC 42023010501
|
| Hospital Charge Code |
25003855
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.10 |
| Rate for Payer: Aetna Commercial |
$132.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.14
|
| Rate for Payer: Cash Price |
$85.99
|
| Rate for Payer: Cigna Commercial |
$142.74
|
| Rate for Payer: First Health Commercial |
$163.38
|
| Rate for Payer: Humana Commercial |
$146.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.34
|
| Rate for Payer: Ohio Health Group HMO |
$128.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.31
|
| Rate for Payer: PHCS Commercial |
$165.10
|
| Rate for Payer: United Healthcare All Payer |
$151.34
|
|
|
BRIDION 200 MG/2ML VIAL
|
Facility
|
IP
|
$551.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.70 |
| Max. Negotiated Rate |
$529.44 |
| Rate for Payer: Aetna Commercial |
$424.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.17
|
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Cigna Commercial |
$457.74
|
| Rate for Payer: First Health Commercial |
$523.92
|
| Rate for Payer: Humana Commercial |
$468.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.32
|
| Rate for Payer: Ohio Health Group HMO |
$413.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.96
|
| Rate for Payer: PHCS Commercial |
$529.44
|
| Rate for Payer: United Healthcare All Payer |
$485.32
|
|
|
BRIDION 200 MG/2ML VIAL
|
Facility
|
OP
|
$551.50
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002905
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.70 |
| Max. Negotiated Rate |
$529.44 |
| Rate for Payer: Aetna Commercial |
$424.66
|
| Rate for Payer: Anthem Medicaid |
$189.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.17
|
| Rate for Payer: Cash Price |
$275.75
|
| Rate for Payer: Cigna Commercial |
$457.74
|
| Rate for Payer: First Health Commercial |
$523.92
|
| Rate for Payer: Humana Commercial |
$468.78
|
| Rate for Payer: Humana KY Medicaid |
$189.66
|
| Rate for Payer: Kentucky WC Medicaid |
$191.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$193.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.32
|
| Rate for Payer: Ohio Health Group HMO |
$413.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.96
|
| Rate for Payer: PHCS Commercial |
$529.44
|
| Rate for Payer: United Healthcare All Payer |
$485.32
|
|
|
BRIDION 500 MG/5ML VIAL
|
Facility
|
OP
|
$654.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002906
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.05 |
| Max. Negotiated Rate |
$628.03 |
| Rate for Payer: Aetna Commercial |
$503.73
|
| Rate for Payer: Anthem Medicaid |
$224.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.28
|
| Rate for Payer: Cash Price |
$327.10
|
| Rate for Payer: Cigna Commercial |
$542.99
|
| Rate for Payer: First Health Commercial |
$621.49
|
| Rate for Payer: Humana Commercial |
$556.07
|
| Rate for Payer: Humana KY Medicaid |
$224.98
|
| Rate for Payer: Kentucky WC Medicaid |
$227.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$536.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$482.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$575.70
|
| Rate for Payer: Ohio Health Group HMO |
$490.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.80
|
| Rate for Payer: PHCS Commercial |
$628.03
|
| Rate for Payer: United Healthcare All Payer |
$575.70
|
|
|
BRIDION 500 MG/5ML VIAL
|
Facility
|
IP
|
$654.20
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002906
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.05 |
| Max. Negotiated Rate |
$628.03 |
| Rate for Payer: Aetna Commercial |
$503.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.28
|
| Rate for Payer: Cash Price |
$327.10
|
| Rate for Payer: Cigna Commercial |
$542.99
|
| Rate for Payer: First Health Commercial |
$621.49
|
| Rate for Payer: Humana Commercial |
$556.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$536.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$482.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$575.70
|
| Rate for Payer: Ohio Health Group HMO |
$490.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.80
|
| Rate for Payer: PHCS Commercial |
$628.03
|
| Rate for Payer: United Healthcare All Payer |
$575.70
|
|
|
Brief check in by md/qhp
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
Brief check in by md/qhp
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS G2012
|
| Hospital Charge Code |
51000021
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$17.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Humana KY Medicaid |
$17.20
|
| Rate for Payer: Kentucky WC Medicaid |
$17.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
