|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480T0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$81.38 |
| Max. Negotiated Rate |
$600.96 |
| Rate for Payer: Aetna Commercial |
$482.02
|
| Rate for Payer: Anthem Medicaid |
$215.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$488.28
|
| Rate for Payer: Cash Price |
$313.00
|
| Rate for Payer: Cigna Commercial |
$519.58
|
| Rate for Payer: First Health Commercial |
$594.70
|
| Rate for Payer: Humana Commercial |
$532.10
|
| Rate for Payer: Humana KY Medicaid |
$215.28
|
| Rate for Payer: Kentucky WC Medicaid |
$217.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$513.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$219.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.88
|
| Rate for Payer: Ohio Health Group HMO |
$469.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$194.06
|
| Rate for Payer: PHCS Commercial |
$600.96
|
| Rate for Payer: United Healthcare All Payer |
$550.88
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480T0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$81.38 |
| Max. Negotiated Rate |
$600.96 |
| Rate for Payer: Aetna Commercial |
$482.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$488.28
|
| Rate for Payer: Cash Price |
$313.00
|
| Rate for Payer: Cigna Commercial |
$519.58
|
| Rate for Payer: First Health Commercial |
$594.70
|
| Rate for Payer: Humana Commercial |
$532.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$513.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.88
|
| Rate for Payer: Ohio Health Group HMO |
$469.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$194.06
|
| Rate for Payer: PHCS Commercial |
$600.96
|
| Rate for Payer: United Healthcare All Payer |
$550.88
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Facility
|
OP
|
$837.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$108.81 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$644.49
|
| Rate for Payer: Anthem Medicaid |
$287.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.86
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$694.71
|
| Rate for Payer: First Health Commercial |
$795.15
|
| Rate for Payer: Humana Commercial |
$711.45
|
| Rate for Payer: Humana KY Medicaid |
$287.84
|
| Rate for Payer: Kentucky WC Medicaid |
$290.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$686.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$617.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$293.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$736.56
|
| Rate for Payer: Ohio Health Group HMO |
$627.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.47
|
| Rate for Payer: PHCS Commercial |
$803.52
|
| Rate for Payer: United Healthcare All Payer |
$736.56
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Facility
|
IP
|
$837.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$108.81 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$644.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$652.86
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$694.71
|
| Rate for Payer: First Health Commercial |
$795.15
|
| Rate for Payer: Humana Commercial |
$711.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$686.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$617.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$736.56
|
| Rate for Payer: Ohio Health Group HMO |
$627.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.47
|
| Rate for Payer: PHCS Commercial |
$803.52
|
| Rate for Payer: United Healthcare All Payer |
$736.56
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Professional
|
Both
|
$837.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$837.00 |
| Rate for Payer: Aetna Commercial |
$126.03
|
| Rate for Payer: Anthem Medicaid |
$72.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$837.00
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cash Price |
$418.50
|
| Rate for Payer: Cigna Commercial |
$133.36
|
| Rate for Payer: Healthspan PPO |
$118.47
|
| Rate for Payer: Humana Medicaid |
$72.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.56
|
| Rate for Payer: Molina Healthcare Passport |
$72.12
|
| Rate for Payer: Multiplan PHCS |
$502.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$585.90
|
| Rate for Payer: UHCCP Medicaid |
$292.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
|
|
DOPPLER ECHOCRADIOGRAPHY
|
Professional
|
Both
|
$75.00
|
|
| Hospital Charge Code |
480P0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
|
|
DOPPLER ECHOCRADIOGRAPHY
|
Facility
|
OP
|
$762.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
480T0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$99.06 |
| Max. Negotiated Rate |
$731.52 |
| Rate for Payer: Aetna Commercial |
$586.74
|
| Rate for Payer: Anthem Medicaid |
$262.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$594.36
|
| Rate for Payer: Cash Price |
$381.00
|
| Rate for Payer: Cigna Commercial |
$632.46
|
| Rate for Payer: First Health Commercial |
$723.90
|
| Rate for Payer: Humana Commercial |
$647.70
|
| Rate for Payer: Humana KY Medicaid |
$262.05
|
| Rate for Payer: Kentucky WC Medicaid |
$264.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$624.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$562.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$670.56
|
| Rate for Payer: Ohio Health Group HMO |
$571.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.22
|
| Rate for Payer: PHCS Commercial |
$731.52
|
| Rate for Payer: United Healthcare All Payer |
$670.56
|
|
|
DOPPLER ECHOCRADIOGRAPHY
|
Facility
|
IP
|
$762.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
480T0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$99.06 |
| Max. Negotiated Rate |
$731.52 |
| Rate for Payer: Aetna Commercial |
$586.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$594.36
|
| Rate for Payer: Cash Price |
$381.00
|
| Rate for Payer: Cigna Commercial |
$632.46
|
| Rate for Payer: First Health Commercial |
$723.90
|
| Rate for Payer: Humana Commercial |
$647.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$624.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$562.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$670.56
|
| Rate for Payer: Ohio Health Group HMO |
$571.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.22
|
| Rate for Payer: PHCS Commercial |
$731.52
|
| Rate for Payer: United Healthcare All Payer |
$670.56
|
|
|
DOPRAM (DOXAPRAM) 4 400MG/20ML
|
Facility
|
IP
|
$322.22
|
|
|
Service Code
|
NDC 641601801
|
| Hospital Charge Code |
25003028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.89 |
| Max. Negotiated Rate |
$309.33 |
| Rate for Payer: Aetna Commercial |
$248.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.33
|
| Rate for Payer: Cash Price |
$161.11
|
| Rate for Payer: Cigna Commercial |
$267.44
|
| Rate for Payer: First Health Commercial |
$306.11
|
| Rate for Payer: Humana Commercial |
$273.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.55
|
| Rate for Payer: Ohio Health Group HMO |
$241.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.89
|
| Rate for Payer: PHCS Commercial |
$309.33
|
| Rate for Payer: United Healthcare All Payer |
$283.55
|
|
|
DOPRAM (DOXAPRAM) 4 400MG/20ML
|
Facility
|
OP
|
$322.22
|
|
|
Service Code
|
NDC 641601801
|
| Hospital Charge Code |
25003028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.89 |
| Max. Negotiated Rate |
$309.33 |
| Rate for Payer: Aetna Commercial |
$248.11
|
| Rate for Payer: Anthem Medicaid |
$110.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.33
|
| Rate for Payer: Cash Price |
$161.11
|
| Rate for Payer: Cigna Commercial |
$267.44
|
| Rate for Payer: First Health Commercial |
$306.11
|
| Rate for Payer: Humana Commercial |
$273.89
|
| Rate for Payer: Humana KY Medicaid |
$110.81
|
| Rate for Payer: Kentucky WC Medicaid |
$111.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.55
|
| Rate for Payer: Ohio Health Group HMO |
$241.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.89
|
| Rate for Payer: PHCS Commercial |
$309.33
|
| Rate for Payer: United Healthcare All Payer |
$283.55
|
|
|
DOSIMETRY BASIC
|
Facility
|
IP
|
$548.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$71.24 |
| Max. Negotiated Rate |
$526.08 |
| Rate for Payer: Aetna Commercial |
$421.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.44
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$454.84
|
| Rate for Payer: First Health Commercial |
$520.60
|
| Rate for Payer: Humana Commercial |
$465.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.24
|
| Rate for Payer: Ohio Health Group HMO |
$411.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.88
|
| Rate for Payer: PHCS Commercial |
$526.08
|
| Rate for Payer: United Healthcare All Payer |
$482.24
|
|
|
DOSIMETRY BASIC
|
Professional
|
Both
|
$548.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$39.72 |
| Max. Negotiated Rate |
$548.00 |
| Rate for Payer: Aetna Commercial |
$110.34
|
| Rate for Payer: Anthem Medicaid |
$62.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$548.00
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Healthspan PPO |
$93.06
|
| Rate for Payer: Humana Medicaid |
$62.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$39.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.21
|
| Rate for Payer: Molina Healthcare Passport |
$62.95
|
| Rate for Payer: Multiplan PHCS |
$328.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$383.60
|
| Rate for Payer: UHCCP Medicaid |
$191.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.58
|
|
|
DOSIMETRY BASIC
|
Facility
|
OP
|
$548.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$71.24 |
| Max. Negotiated Rate |
$526.08 |
| Rate for Payer: Aetna Commercial |
$421.96
|
| Rate for Payer: Anthem Medicaid |
$188.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$117.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$164.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.40
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cash Price |
$274.00
|
| Rate for Payer: Cigna Commercial |
$454.84
|
| Rate for Payer: First Health Commercial |
$520.60
|
| Rate for Payer: Humana Commercial |
$465.80
|
| Rate for Payer: Humana KY Medicaid |
$188.46
|
| Rate for Payer: Humana Medicare Advantage |
$117.33
|
| Rate for Payer: Kentucky WC Medicaid |
$190.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$449.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$482.24
|
| Rate for Payer: Ohio Health Group HMO |
$411.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.88
|
| Rate for Payer: PHCS Commercial |
$526.08
|
| Rate for Payer: United Healthcare All Payer |
$482.24
|
|
|
DOSIMETRY BASIC(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
333P0006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$39.72 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$110.34
|
| Rate for Payer: Anthem Medicaid |
$62.95
|
| 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 |
$118.68
|
| Rate for Payer: Healthspan PPO |
$93.06
|
| Rate for Payer: Humana Medicaid |
$62.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$39.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.21
|
| Rate for Payer: Molina Healthcare Passport |
$62.95
|
| 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 |
$63.58
|
|
|
DOSIMETRY BASIC(T
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
333T0006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$382.08 |
| Rate for Payer: Aetna Commercial |
$306.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$310.44
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$330.34
|
| Rate for Payer: First Health Commercial |
$378.10
|
| Rate for Payer: Humana Commercial |
$338.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$326.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$293.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$350.24
|
| Rate for Payer: Ohio Health Group HMO |
$298.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.38
|
| Rate for Payer: PHCS Commercial |
$382.08
|
| Rate for Payer: United Healthcare All Payer |
$350.24
|
|
|
DOSIMETRY BASIC(T
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
333T0006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$382.08 |
| Rate for Payer: Aetna Commercial |
$306.46
|
| Rate for Payer: Anthem Medicaid |
$136.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$117.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$310.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$164.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.40
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$330.34
|
| Rate for Payer: First Health Commercial |
$378.10
|
| Rate for Payer: Humana Commercial |
$338.30
|
| Rate for Payer: Humana KY Medicaid |
$136.87
|
| Rate for Payer: Humana Medicare Advantage |
$117.33
|
| Rate for Payer: Kentucky WC Medicaid |
$138.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$326.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$293.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$139.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$350.24
|
| Rate for Payer: Ohio Health Group HMO |
$298.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.38
|
| Rate for Payer: PHCS Commercial |
$382.08
|
| Rate for Payer: United Healthcare All Payer |
$350.24
|
|
|
DOSTINEX 0.5MG TABLET
|
Facility
|
IP
|
$22.85
|
|
|
Service Code
|
HCPCS J8515
|
| Hospital Charge Code |
25002532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Humana Commercial |
$19.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.11
|
| Rate for Payer: Ohio Health Group HMO |
$17.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.08
|
| Rate for Payer: PHCS Commercial |
$21.94
|
| Rate for Payer: United Healthcare All Payer |
$20.11
|
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.82
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cigna Commercial |
$18.97
|
| Rate for Payer: First Health Commercial |
$21.71
|
|
|
DOSTINEX 0.5MG TABLET
|
Facility
|
OP
|
$22.85
|
|
|
Service Code
|
HCPCS J8515
|
| Hospital Charge Code |
25002532
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$21.94 |
| Rate for Payer: Aetna Commercial |
$17.59
|
| Rate for Payer: Anthem Medicaid |
$7.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.82
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Cigna Commercial |
$18.97
|
| Rate for Payer: First Health Commercial |
$21.71
|
| Rate for Payer: Humana Commercial |
$19.42
|
| Rate for Payer: Humana KY Medicaid |
$7.86
|
| Rate for Payer: Kentucky WC Medicaid |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.11
|
| Rate for Payer: Ohio Health Group HMO |
$17.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.08
|
| Rate for Payer: PHCS Commercial |
$21.94
|
| Rate for Payer: United Healthcare All Payer |
$20.11
|
|
|
DOTAREM 0.5MMOL/ML 100ML VIAL
|
Facility
|
IP
|
$862.85
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.17 |
| Max. Negotiated Rate |
$828.34 |
| Rate for Payer: Aetna Commercial |
$664.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.02
|
| Rate for Payer: Cash Price |
$431.42
|
| Rate for Payer: Cigna Commercial |
$716.17
|
| Rate for Payer: First Health Commercial |
$819.71
|
| Rate for Payer: Humana Commercial |
$733.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$759.31
|
| Rate for Payer: Ohio Health Group HMO |
$647.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.48
|
| Rate for Payer: PHCS Commercial |
$828.34
|
| Rate for Payer: United Healthcare All Payer |
$759.31
|
|
|
DOTAREM 0.5MMOL/ML 100ML VIAL
|
Facility
|
OP
|
$862.85
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.17 |
| Max. Negotiated Rate |
$828.34 |
| Rate for Payer: Aetna Commercial |
$664.39
|
| Rate for Payer: Anthem Medicaid |
$296.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.02
|
| Rate for Payer: Cash Price |
$431.42
|
| Rate for Payer: Cigna Commercial |
$716.17
|
| Rate for Payer: First Health Commercial |
$819.71
|
| Rate for Payer: Humana Commercial |
$733.42
|
| Rate for Payer: Humana KY Medicaid |
$296.73
|
| Rate for Payer: Kentucky WC Medicaid |
$299.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$707.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$759.31
|
| Rate for Payer: Ohio Health Group HMO |
$647.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.48
|
| Rate for Payer: PHCS Commercial |
$828.34
|
| Rate for Payer: United Healthcare All Payer |
$759.31
|
|
|
DOTAREM 0.5MMOL/ML 10ML VIAL
|
Facility
|
OP
|
$88.80
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$85.25 |
| Rate for Payer: Aetna Commercial |
$68.38
|
| Rate for Payer: Anthem Medicaid |
$30.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.26
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$73.70
|
| Rate for Payer: First Health Commercial |
$84.36
|
| Rate for Payer: Humana Commercial |
$75.48
|
| Rate for Payer: Humana KY Medicaid |
$30.54
|
| Rate for Payer: Kentucky WC Medicaid |
$30.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.14
|
| Rate for Payer: Ohio Health Group HMO |
$66.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.53
|
| Rate for Payer: PHCS Commercial |
$85.25
|
| Rate for Payer: United Healthcare All Payer |
$78.14
|
|
|
DOTAREM 0.5MMOL/ML 10ML VIAL
|
Facility
|
IP
|
$88.80
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$85.25 |
| Rate for Payer: Aetna Commercial |
$68.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.26
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cigna Commercial |
$73.70
|
| Rate for Payer: First Health Commercial |
$84.36
|
| Rate for Payer: Humana Commercial |
$75.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.14
|
| Rate for Payer: Ohio Health Group HMO |
$66.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.53
|
| Rate for Payer: PHCS Commercial |
$85.25
|
| Rate for Payer: United Healthcare All Payer |
$78.14
|
|
|
DOTAREM 0.5MMOL/ML 15ML VIAL
|
Facility
|
IP
|
$133.20
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$127.87 |
| Rate for Payer: Aetna Commercial |
$102.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.90
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$110.56
|
| Rate for Payer: First Health Commercial |
$126.54
|
| Rate for Payer: Humana Commercial |
$113.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.22
|
| Rate for Payer: Ohio Health Group HMO |
$99.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.29
|
| Rate for Payer: PHCS Commercial |
$127.87
|
| Rate for Payer: United Healthcare All Payer |
$117.22
|
|
|
DOTAREM 0.5MMOL/ML 15ML VIAL
|
Facility
|
OP
|
$133.20
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$127.87 |
| Rate for Payer: Aetna Commercial |
$102.56
|
| Rate for Payer: Anthem Medicaid |
$45.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.90
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Cigna Commercial |
$110.56
|
| Rate for Payer: First Health Commercial |
$126.54
|
| Rate for Payer: Humana Commercial |
$113.22
|
| Rate for Payer: Humana KY Medicaid |
$45.81
|
| Rate for Payer: Kentucky WC Medicaid |
$46.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.22
|
| Rate for Payer: Ohio Health Group HMO |
$99.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.29
|
| Rate for Payer: PHCS Commercial |
$127.87
|
| Rate for Payer: United Healthcare All Payer |
$117.22
|
|
|
DOTAREM 0.5MMOL/ML 20ML VIAL
|
Facility
|
OP
|
$177.60
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.09 |
| Max. Negotiated Rate |
$170.50 |
| Rate for Payer: Aetna Commercial |
$136.75
|
| Rate for Payer: Anthem Medicaid |
$61.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$138.53
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$147.41
|
| Rate for Payer: First Health Commercial |
$168.72
|
| Rate for Payer: Humana Commercial |
$150.96
|
| Rate for Payer: Humana KY Medicaid |
$61.08
|
| Rate for Payer: Kentucky WC Medicaid |
$61.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$156.29
|
| Rate for Payer: Ohio Health Group HMO |
$133.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.06
|
| Rate for Payer: PHCS Commercial |
$170.50
|
| Rate for Payer: United Healthcare All Payer |
$156.29
|
|
