|
COMPART SYNDROME MEASURING(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 20950
|
| Hospital Charge Code |
761P0358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.33 |
| Max. Negotiated Rate |
$305.66 |
| Rate for Payer: Aetna Commercial |
$135.14
|
| Rate for Payer: Ambetter Exchange |
$83.80
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.33
|
| Rate for Payer: Anthem Medicaid |
$70.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$83.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$83.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$100.56
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$148.09
|
| Rate for Payer: Healthspan PPO |
$305.66
|
| Rate for Payer: Humana Medicaid |
$70.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$112.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$83.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.75
|
| Rate for Payer: Molina Healthcare Passport |
$70.34
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$108.94
|
| Rate for Payer: UHCCP Medicaid |
$49.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.04
|
| Rate for Payer: Wellcare Medicare Advantage |
$83.80
|
|
|
COMPART SYNDROME MEASURING(T
|
Facility
|
OP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 20950
|
| Hospital Charge Code |
761T0358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$353.87 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem Medicaid |
$353.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Humana KY Medicaid |
$353.87
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$357.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$360.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.01
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
COMPART SYNDROME MEASURING(T
|
Facility
|
IP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 20950
|
| Hospital Charge Code |
761T0358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$308.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.01
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
COMPATIBILITY TEST AGT EA
|
Facility
|
IP
|
$248.00
|
|
|
Service Code
|
HCPCS 86922
|
| Hospital Charge Code |
30001238
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.40 |
| Max. Negotiated Rate |
$238.08 |
| Rate for Payer: Aetna Commercial |
$190.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$199.14
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cigna Commercial |
$205.84
|
| Rate for Payer: First Health Commercial |
$235.60
|
| Rate for Payer: Humana Commercial |
$210.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$203.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$183.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$218.24
|
| Rate for Payer: Ohio Health Group HMO |
$186.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$198.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$215.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$171.12
|
| Rate for Payer: PHCS Commercial |
$238.08
|
| Rate for Payer: United Healthcare All Payer |
$218.24
|
|
|
COMPATIBILITY TEST AGT EA
|
Facility
|
OP
|
$248.00
|
|
|
Service Code
|
HCPCS 86922
|
| Hospital Charge Code |
30001238
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$158.33 |
| Max. Negotiated Rate |
$238.08 |
| Rate for Payer: Aetna Commercial |
$190.96
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$199.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cigna Commercial |
$205.84
|
| Rate for Payer: First Health Commercial |
$235.60
|
| Rate for Payer: Humana Commercial |
$210.80
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$203.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$183.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$218.24
|
| Rate for Payer: Ohio Health Group HMO |
$186.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$198.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$215.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$171.12
|
| Rate for Payer: PHCS Commercial |
$238.08
|
| Rate for Payer: United Healthcare All Payer |
$218.24
|
|
|
COMPATIBILITY TEST IMMED. SPIN
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 86920
|
| Hospital Charge Code |
30001236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
COMPATIBILITY TEST IMMED. SPIN
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 86920
|
| Hospital Charge Code |
30001236
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.63 |
| Max. Negotiated Rate |
$221.66 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
COMPATIBIL TEST INCUB EA UNIT
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
HCPCS 86921
|
| Hospital Charge Code |
30001237
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$217.92 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
COMPATIBIL TEST INCUB EA UNIT
|
Facility
|
OP
|
$227.00
|
|
|
Service Code
|
HCPCS 86921
|
| Hospital Charge Code |
30001237
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.63 |
| Max. Negotiated Rate |
$221.66 |
| Rate for Payer: Aetna Commercial |
$174.79
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$182.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cash Price |
$113.50
|
| Rate for Payer: Cigna Commercial |
$188.41
|
| Rate for Payer: First Health Commercial |
$215.65
|
| Rate for Payer: Humana Commercial |
$192.95
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$167.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$199.76
|
| Rate for Payer: Ohio Health Group HMO |
$170.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$156.63
|
| Rate for Payer: PHCS Commercial |
$217.92
|
| Rate for Payer: United Healthcare All Payer |
$199.76
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
63600194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
25001969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
63600194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
63600194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$69.60 |
| Rate for Payer: Aetna Commercial |
$6.48
|
| Rate for Payer: Ambetter Exchange |
$2.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.02
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Healthspan PPO |
$1.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$7.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.52
|
| Rate for Payer: Multiplan PHCS |
$69.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3.28
|
| Rate for Payer: UHCCP Medicaid |
$40.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$2.52
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
636T0194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
636T0194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLOR)10 10MG/2ML
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
25001969
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
COMPAZINE(PROCHLORPE 10MG/1TAB
|
Facility
|
IP
|
$4.72
|
|
|
Service Code
|
NDC 59746011506
|
| Hospital Charge Code |
25000451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
COMPAZINE(PROCHLORPE 10MG/1TAB
|
Facility
|
OP
|
$4.72
|
|
|
Service Code
|
NDC 59746011506
|
| Hospital Charge Code |
25000451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Cash Price |
$2.36
|
| Rate for Payer: Cigna Commercial |
$3.92
|
| Rate for Payer: First Health Commercial |
$4.48
|
| Rate for Payer: Humana Commercial |
$4.01
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.15
|
| Rate for Payer: Ohio Health Group HMO |
$3.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.53
|
| Rate for Payer: United Healthcare All Payer |
$4.15
|
|
|
COMPAZINE(PROCHLORPER 25MG/1EA
|
Facility
|
OP
|
$25.71
|
|
|
Service Code
|
NDC 574722612
|
| Hospital Charge Code |
25000452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$24.68 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Anthem Medicaid |
$8.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.05
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cigna Commercial |
$21.34
|
| Rate for Payer: First Health Commercial |
$24.42
|
| Rate for Payer: Humana Commercial |
$21.85
|
| Rate for Payer: Humana KY Medicaid |
$8.84
|
| Rate for Payer: Kentucky WC Medicaid |
$8.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.62
|
| Rate for Payer: Ohio Health Group HMO |
$19.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.74
|
| Rate for Payer: PHCS Commercial |
$24.68
|
| Rate for Payer: United Healthcare All Payer |
$22.62
|
|
|
COMPAZINE(PROCHLORPER 25MG/1EA
|
Facility
|
IP
|
$25.71
|
|
|
Service Code
|
NDC 574722612
|
| Hospital Charge Code |
25000452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$24.68 |
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.05
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cigna Commercial |
$21.34
|
| Rate for Payer: First Health Commercial |
$24.42
|
| Rate for Payer: Humana Commercial |
$21.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.62
|
| Rate for Payer: Ohio Health Group HMO |
$19.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.74
|
| Rate for Payer: PHCS Commercial |
$24.68
|
| Rate for Payer: United Healthcare All Payer |
$22.62
|
|
|
COMPAZINE(PROCHLORPER 5MG/1TAB
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
25002706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
COMPAZINE(PROCHLORPER 5MG/1TAB
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
25002706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
COMPLETE SKELETAL BONE SURVE(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
320P0236
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$151.21 |
| Rate for Payer: Aetna Commercial |
$151.21
|
| Rate for Payer: Ambetter Exchange |
$89.30
|
| Rate for Payer: Anthem Medicaid |
$62.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$89.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$89.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$107.16
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$131.65
|
| Rate for Payer: Healthspan PPO |
$141.69
|
| Rate for Payer: Humana Medicaid |
$62.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.99
|
| Rate for Payer: Molina Healthcare Passport |
$62.74
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$116.09
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$89.30
|
|
|
COMPLETE SKELETAL BONE SURVE(T
|
Facility
|
IP
|
$676.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
320T0236
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$202.80 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$466.44
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
|
COMPLETE SKELETAL BONE SURVE(T
|
Facility
|
OP
|
$676.00
|
|
|
Service Code
|
HCPCS 77075
|
| Hospital Charge Code |
320T0236
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem Medicaid |
$232.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Humana KY Medicaid |
$232.48
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$234.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$237.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$466.44
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
