|
BROMFED DM SYRUP 5 ML
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 121093304
|
| Hospital Charge Code |
25000347
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
BROMFED DM SYRUP 5 ML
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 121093304
|
| Hospital Charge Code |
25000347
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
BROMFENAC 0.09% EYEDROP 2.5 ML
|
Facility
|
IP
|
$16.48
|
|
|
Service Code
|
NDC 72266014201
|
| Hospital Charge Code |
25002907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$15.82 |
| Rate for Payer: Aetna Commercial |
$12.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.85
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cigna Commercial |
$13.68
|
| Rate for Payer: First Health Commercial |
$15.66
|
| Rate for Payer: Humana Commercial |
$14.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.50
|
| Rate for Payer: Ohio Health Group HMO |
$12.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.37
|
| Rate for Payer: PHCS Commercial |
$15.82
|
| Rate for Payer: United Healthcare All Payer |
$14.50
|
|
|
BROMFENAC 0.09% EYEDROP 2.5 ML
|
Facility
|
OP
|
$16.48
|
|
|
Service Code
|
NDC 72266014201
|
| Hospital Charge Code |
25002907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$15.82 |
| Rate for Payer: Aetna Commercial |
$12.69
|
| Rate for Payer: Anthem Medicaid |
$5.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.85
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cigna Commercial |
$13.68
|
| Rate for Payer: First Health Commercial |
$15.66
|
| Rate for Payer: Humana Commercial |
$14.01
|
| Rate for Payer: Humana KY Medicaid |
$5.67
|
| Rate for Payer: Kentucky WC Medicaid |
$5.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$14.50
|
| Rate for Payer: Ohio Health Group HMO |
$12.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.37
|
| Rate for Payer: PHCS Commercial |
$15.82
|
| Rate for Payer: United Healthcare All Payer |
$14.50
|
|
|
BRONCH EBUS IVNTJ PERPH LES
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 31654
|
| Hospital Charge Code |
41000058
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$116.52 |
| Rate for Payer: Ambetter Exchange |
$62.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$54.88
|
| Rate for Payer: Anthem Medicaid |
$84.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.76
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$116.52
|
| Rate for Payer: Humana Medicaid |
$84.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.67
|
| Rate for Payer: Molina Healthcare Passport |
$84.97
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.99
|
| Rate for Payer: UHCCP Medicaid |
$57.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.30
|
|
|
BRONCH EBUS IVNTJ PERPH LES(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 31654
|
| Hospital Charge Code |
410P0058
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$116.52 |
| Rate for Payer: Ambetter Exchange |
$62.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$54.88
|
| Rate for Payer: Anthem Medicaid |
$84.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.76
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$116.52
|
| Rate for Payer: Humana Medicaid |
$84.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.67
|
| Rate for Payer: Molina Healthcare Passport |
$84.97
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.99
|
| Rate for Payer: UHCCP Medicaid |
$57.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.30
|
|
|
BRONCH EBUS IVNTJ PERPH LES(T
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS 31654
|
| Hospital Charge Code |
410T0058
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$757.20 |
| Max. Negotiated Rate |
$2,423.04 |
| Rate for Payer: Aetna Commercial |
$1,943.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,968.72
|
| Rate for Payer: Cash Price |
$1,262.00
|
| Rate for Payer: Cigna Commercial |
$2,094.92
|
| Rate for Payer: First Health Commercial |
$2,397.80
|
| Rate for Payer: Humana Commercial |
$2,145.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,069.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,862.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$757.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,221.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,893.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,019.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,195.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,741.56
|
| Rate for Payer: PHCS Commercial |
$2,423.04
|
| Rate for Payer: United Healthcare All Payer |
$2,221.12
|
|
|
BRONCH EBUS IVNTJ PERPH LES(T
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS 31654
|
| Hospital Charge Code |
410T0058
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$757.20 |
| Max. Negotiated Rate |
$2,423.04 |
| Rate for Payer: Aetna Commercial |
$1,943.48
|
| Rate for Payer: Anthem Medicaid |
$868.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,968.72
|
| Rate for Payer: Cash Price |
$1,262.00
|
| Rate for Payer: Cigna Commercial |
$2,094.92
|
| Rate for Payer: First Health Commercial |
$2,397.80
|
| Rate for Payer: Humana Commercial |
$2,145.40
|
| Rate for Payer: Humana KY Medicaid |
$868.00
|
| Rate for Payer: Kentucky WC Medicaid |
$876.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,069.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,862.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$757.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$885.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,221.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,893.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,019.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,195.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,741.56
|
| Rate for Payer: PHCS Commercial |
$2,423.04
|
| Rate for Payer: United Healthcare All Payer |
$2,221.12
|
|
|
BRONCH EBUS SAMPLNG 1/2 NODE
|
Facility
|
OP
|
$460.00
|
|
|
Service Code
|
HCPCS 31652
|
| Hospital Charge Code |
41000056
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$158.19 |
| Max. Negotiated Rate |
$4,769.34 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem Medicaid |
$158.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,406.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,769.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,599.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Humana KY Medicaid |
$158.19
|
| Rate for Payer: Humana Medicare Advantage |
$3,406.67
|
| Rate for Payer: Kentucky WC Medicaid |
$159.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,088.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$400.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$317.40
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
BRONCH EBUS SAMPLNG 1/2 NODE
|
Facility
|
IP
|
$460.00
|
|
|
Service Code
|
HCPCS 31652
|
| Hospital Charge Code |
41000056
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$138.00 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$354.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$358.80
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: First Health Commercial |
$437.00
|
| Rate for Payer: Humana Commercial |
$391.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$377.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$339.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$404.80
|
| Rate for Payer: Ohio Health Group HMO |
$345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$400.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$317.40
|
| Rate for Payer: PHCS Commercial |
$441.60
|
| Rate for Payer: United Healthcare All Payer |
$404.80
|
|
|
BRONCH EBUS SAMPLNG 1/2 NODE
|
Professional
|
Both
|
$460.00
|
|
|
Service Code
|
HCPCS 31652
|
| Hospital Charge Code |
41000056
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$189.60 |
| Max. Negotiated Rate |
$695.46 |
| Rate for Payer: Ambetter Exchange |
$205.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$189.60
|
| Rate for Payer: Anthem Medicaid |
$681.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$205.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$246.59
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$402.77
|
| Rate for Payer: Humana Medicaid |
$681.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$302.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$205.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$205.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$695.46
|
| Rate for Payer: Molina Healthcare Passport |
$681.82
|
| Rate for Payer: Multiplan PHCS |
$276.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$267.14
|
| Rate for Payer: UHCCP Medicaid |
$199.08
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$688.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$205.49
|
|
|
BRONCH EBUS SAMPLNG 1/2 NOD(P
|
Professional
|
Both
|
$460.00
|
|
|
Service Code
|
HCPCS 31652
|
| Hospital Charge Code |
410P0056
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$189.60 |
| Max. Negotiated Rate |
$695.46 |
| Rate for Payer: Ambetter Exchange |
$205.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$189.60
|
| Rate for Payer: Anthem Medicaid |
$681.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$205.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$205.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$246.59
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cash Price |
$230.00
|
| Rate for Payer: Cigna Commercial |
$402.77
|
| Rate for Payer: Humana Medicaid |
$681.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$302.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$205.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$205.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$695.46
|
| Rate for Payer: Molina Healthcare Passport |
$681.82
|
| Rate for Payer: Multiplan PHCS |
$276.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$267.14
|
| Rate for Payer: UHCCP Medicaid |
$199.08
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$688.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$205.49
|
|
|
BRONCH EBUS SAMPLNG 3/> NODE
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
HCPCS 31653
|
| Hospital Charge Code |
41000057
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.20
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$338.10
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
BRONCH EBUS SAMPLNG 3/> NODE
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
HCPCS 31653
|
| Hospital Charge Code |
41000057
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$209.30 |
| Max. Negotiated Rate |
$739.77 |
| Rate for Payer: Ambetter Exchange |
$227.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$209.30
|
| Rate for Payer: Anthem Medicaid |
$725.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$273.35
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$444.58
|
| Rate for Payer: Humana Medicaid |
$725.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$333.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$739.77
|
| Rate for Payer: Molina Healthcare Passport |
$725.26
|
| Rate for Payer: Multiplan PHCS |
$294.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$296.13
|
| Rate for Payer: UHCCP Medicaid |
$219.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$732.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.79
|
|
|
BRONCH EBUS SAMPLNG 3/> NODE
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
HCPCS 31653
|
| Hospital Charge Code |
41000057
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$168.51 |
| Max. Negotiated Rate |
$4,769.34 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem Medicaid |
$168.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,406.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,769.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,599.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Humana KY Medicaid |
$168.51
|
| Rate for Payer: Humana Medicare Advantage |
$3,406.67
|
| Rate for Payer: Kentucky WC Medicaid |
$170.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,088.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$171.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$338.10
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
BRONCH EBUS SAMPLNG 3/> NOD(P
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
HCPCS 31653
|
| Hospital Charge Code |
410P0057
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$209.30 |
| Max. Negotiated Rate |
$739.77 |
| Rate for Payer: Ambetter Exchange |
$227.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$209.30
|
| Rate for Payer: Anthem Medicaid |
$725.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$273.35
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$444.58
|
| Rate for Payer: Humana Medicaid |
$725.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$333.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$739.77
|
| Rate for Payer: Molina Healthcare Passport |
$725.26
|
| Rate for Payer: Multiplan PHCS |
$294.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$296.13
|
| Rate for Payer: UHCCP Medicaid |
$219.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$732.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.79
|
|
|
BRONCHIAL PROVOCATION - GAS
|
Professional
|
Both
|
$924.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
46000023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$31.35 |
| Max. Negotiated Rate |
$554.40 |
| Rate for Payer: Aetna Commercial |
$53.98
|
| Rate for Payer: Ambetter Exchange |
$31.35
|
| Rate for Payer: Anthem Medicaid |
$58.69
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.62
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cigna Commercial |
$106.45
|
| Rate for Payer: Healthspan PPO |
$72.60
|
| Rate for Payer: Humana Medicaid |
$58.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.86
|
| Rate for Payer: Molina Healthcare Passport |
$58.69
|
| Rate for Payer: Multiplan PHCS |
$554.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.76
|
| Rate for Payer: UHCCP Medicaid |
$323.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.35
|
|
|
BRONCHIAL PROVOCATION - GAS
|
Facility
|
IP
|
$924.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
46000023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$887.04 |
| Rate for Payer: Aetna Commercial |
$711.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$720.72
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cigna Commercial |
$766.92
|
| Rate for Payer: First Health Commercial |
$877.80
|
| Rate for Payer: Humana Commercial |
$785.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$757.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$681.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$277.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$813.12
|
| Rate for Payer: Ohio Health Group HMO |
$693.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$739.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$803.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$637.56
|
| Rate for Payer: PHCS Commercial |
$887.04
|
| Rate for Payer: United Healthcare All Payer |
$813.12
|
|
|
BRONCHIAL PROVOCATION - GAS
|
Facility
|
OP
|
$924.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
46000023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$317.76 |
| Max. Negotiated Rate |
$887.04 |
| Rate for Payer: Aetna Commercial |
$711.48
|
| Rate for Payer: Anthem Medicaid |
$317.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$720.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cigna Commercial |
$766.92
|
| Rate for Payer: First Health Commercial |
$877.80
|
| Rate for Payer: Humana Commercial |
$785.40
|
| Rate for Payer: Humana KY Medicaid |
$317.76
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$321.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$757.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$681.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$324.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$813.12
|
| Rate for Payer: Ohio Health Group HMO |
$693.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$739.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$803.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$637.56
|
| Rate for Payer: PHCS Commercial |
$887.04
|
| Rate for Payer: United Healthcare All Payer |
$813.12
|
|
|
BRONCHIAL PROVOCATION - GAS(P
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
460P0023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$31.35 |
| Max. Negotiated Rate |
$106.45 |
| Rate for Payer: Aetna Commercial |
$53.98
|
| Rate for Payer: Ambetter Exchange |
$31.35
|
| Rate for Payer: Anthem Medicaid |
$58.69
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.62
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$106.45
|
| Rate for Payer: Healthspan PPO |
$72.60
|
| Rate for Payer: Humana Medicaid |
$58.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.86
|
| Rate for Payer: Molina Healthcare Passport |
$58.69
|
| Rate for Payer: Multiplan PHCS |
$93.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$40.76
|
| Rate for Payer: UHCCP Medicaid |
$54.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.35
|
|
|
BRONCHIAL PROVOCATION - GAS(T
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
460T0023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$264.12 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
BRONCHIAL PROVOCATION - GAS(T
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 95070
|
| Hospital Charge Code |
460T0023
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
BRONCHIAL PROVOCATION TEST
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
HCPCS 94070
|
| Hospital Charge Code |
46000003
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$189.15 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem Medicaid |
$189.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Humana KY Medicaid |
$189.15
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$191.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
BRONCHIAL PROVOCATION TEST
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 94070
|
| Hospital Charge Code |
46000003
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna Commercial |
$94.19
|
| Rate for Payer: Ambetter Exchange |
$57.87
|
| Rate for Payer: Anthem Medicaid |
$68.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$57.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$57.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$69.44
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$86.67
|
| Rate for Payer: Healthspan PPO |
$72.96
|
| Rate for Payer: Humana Medicaid |
$68.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$57.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.60
|
| Rate for Payer: Molina Healthcare Passport |
$68.24
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$75.23
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$57.87
|
|
|
BRONCHIAL PROVOCATION TEST
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
HCPCS 94070
|
| Hospital Charge Code |
46000003
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
