|
DONNATAL (BELLAD/PB) ELIXI 5ML
|
Facility
|
OP
|
$11.07
|
|
|
Service Code
|
NDC 50742066516
|
| Hospital Charge Code |
25003026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Aetna Commercial |
$8.52
|
| Rate for Payer: Anthem Medicaid |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.63
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.19
|
| Rate for Payer: First Health Commercial |
$10.52
|
| Rate for Payer: Humana Commercial |
$9.41
|
| Rate for Payer: Humana KY Medicaid |
$3.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.74
|
| Rate for Payer: Ohio Health Group HMO |
$8.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.64
|
| Rate for Payer: PHCS Commercial |
$10.63
|
| Rate for Payer: United Healthcare All Payer |
$9.74
|
|
|
DONNATAL (BELLAD/PB) TABL 1TAB
|
Facility
|
OP
|
$30.91
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
25003027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.27 |
| Max. Negotiated Rate |
$29.67 |
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Anthem Medicaid |
$10.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.11
|
| Rate for Payer: Cash Price |
$15.46
|
| Rate for Payer: Cigna Commercial |
$25.66
|
| Rate for Payer: First Health Commercial |
$29.36
|
| Rate for Payer: Humana Commercial |
$26.27
|
| Rate for Payer: Humana KY Medicaid |
$10.63
|
| Rate for Payer: Kentucky WC Medicaid |
$10.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.20
|
| Rate for Payer: Ohio Health Group HMO |
$23.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.33
|
| Rate for Payer: PHCS Commercial |
$29.67
|
| Rate for Payer: United Healthcare All Payer |
$27.20
|
|
|
DONNATAL (BELLAD/PB) TABL 1TAB
|
Facility
|
IP
|
$30.91
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
25003027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.27 |
| Max. Negotiated Rate |
$29.67 |
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.11
|
| Rate for Payer: Cash Price |
$15.46
|
| Rate for Payer: Cigna Commercial |
$25.66
|
| Rate for Payer: First Health Commercial |
$29.36
|
| Rate for Payer: Humana Commercial |
$26.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.20
|
| Rate for Payer: Ohio Health Group HMO |
$23.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.33
|
| Rate for Payer: PHCS Commercial |
$29.67
|
| Rate for Payer: United Healthcare All Payer |
$27.20
|
|
|
DOPAMINE 400 MG 10 ML VIAL
|
Facility
|
IP
|
$112.83
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.32 |
| Rate for Payer: Aetna Commercial |
$86.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cigna Commercial |
$93.65
|
| Rate for Payer: First Health Commercial |
$107.19
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.29
|
| Rate for Payer: Ohio Health Group HMO |
$84.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.85
|
| Rate for Payer: PHCS Commercial |
$108.32
|
| Rate for Payer: United Healthcare All Payer |
$99.29
|
|
|
DOPAMINE 400 MG 10 ML VIAL
|
Facility
|
OP
|
$112.83
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$108.32 |
| Rate for Payer: Aetna Commercial |
$86.88
|
| Rate for Payer: Anthem Medicaid |
$38.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.01
|
| Rate for Payer: Cash Price |
$56.42
|
| Rate for Payer: Cigna Commercial |
$93.65
|
| Rate for Payer: First Health Commercial |
$107.19
|
| Rate for Payer: Humana Commercial |
$95.91
|
| Rate for Payer: Humana KY Medicaid |
$38.80
|
| Rate for Payer: Kentucky WC Medicaid |
$39.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.29
|
| Rate for Payer: Ohio Health Group HMO |
$84.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.85
|
| Rate for Payer: PHCS Commercial |
$108.32
|
| Rate for Payer: United Healthcare All Payer |
$99.29
|
|
|
DOPAMINE 800MG DEXTROSE 250ML
|
Facility
|
IP
|
$129.65
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.90 |
| Max. Negotiated Rate |
$124.46 |
| Rate for Payer: Aetna Commercial |
$99.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.13
|
| Rate for Payer: Cash Price |
$64.83
|
| Rate for Payer: Cigna Commercial |
$107.61
|
| Rate for Payer: First Health Commercial |
$123.17
|
| Rate for Payer: Humana Commercial |
$110.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.09
|
| Rate for Payer: Ohio Health Group HMO |
$97.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.46
|
| Rate for Payer: PHCS Commercial |
$124.46
|
| Rate for Payer: United Healthcare All Payer |
$114.09
|
|
|
DOPAMINE 800MG DEXTROSE 250ML
|
Facility
|
OP
|
$129.65
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
25002044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.90 |
| Max. Negotiated Rate |
$124.46 |
| Rate for Payer: Aetna Commercial |
$99.83
|
| Rate for Payer: Anthem Medicaid |
$44.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$101.13
|
| Rate for Payer: Cash Price |
$64.83
|
| Rate for Payer: Cigna Commercial |
$107.61
|
| Rate for Payer: First Health Commercial |
$123.17
|
| Rate for Payer: Humana Commercial |
$110.20
|
| Rate for Payer: Humana KY Medicaid |
$44.59
|
| Rate for Payer: Kentucky WC Medicaid |
$45.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.09
|
| Rate for Payer: Ohio Health Group HMO |
$97.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.46
|
| Rate for Payer: PHCS Commercial |
$124.46
|
| Rate for Payer: United Healthcare All Payer |
$114.09
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
IP
|
$667.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480T0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$200.10 |
| Max. Negotiated Rate |
$640.32 |
| Rate for Payer: Aetna Commercial |
$513.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$520.26
|
| Rate for Payer: Cash Price |
$333.50
|
| Rate for Payer: Cigna Commercial |
$553.61
|
| Rate for Payer: First Health Commercial |
$633.65
|
| Rate for Payer: Humana Commercial |
$566.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$546.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$492.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$200.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$586.96
|
| Rate for Payer: Ohio Health Group HMO |
$500.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$533.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$460.23
|
| Rate for Payer: PHCS Commercial |
$640.32
|
| Rate for Payer: United Healthcare All Payer |
$586.96
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
OP
|
$667.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480T0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$200.10 |
| Max. Negotiated Rate |
$640.32 |
| Rate for Payer: Aetna Commercial |
$513.59
|
| Rate for Payer: Anthem Medicaid |
$229.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$520.26
|
| Rate for Payer: Cash Price |
$333.50
|
| Rate for Payer: Cigna Commercial |
$553.61
|
| Rate for Payer: First Health Commercial |
$633.65
|
| Rate for Payer: Humana Commercial |
$566.95
|
| Rate for Payer: Humana KY Medicaid |
$229.38
|
| Rate for Payer: Kentucky WC Medicaid |
$231.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$546.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$492.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$200.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$233.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$586.96
|
| Rate for Payer: Ohio Health Group HMO |
$500.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$533.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$460.23
|
| Rate for Payer: PHCS Commercial |
$640.32
|
| Rate for Payer: United Healthcare All Payer |
$586.96
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Professional
|
Both
|
$887.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$532.20 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Ambetter Exchange |
$20.24
|
| Rate for Payer: Anthem Medicaid |
$83.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$20.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$20.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.29
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$152.50
|
| Rate for Payer: Healthspan PPO |
$83.34
|
| Rate for Payer: Humana Medicaid |
$83.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$20.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.89
|
| Rate for Payer: Molina Healthcare Passport |
$83.23
|
| Rate for Payer: Multiplan PHCS |
$532.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$26.31
|
| Rate for Payer: UHCCP Medicaid |
$310.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.24
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
48000110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem Medicaid |
$305.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Humana KY Medicaid |
$305.04
|
| Rate for Payer: Kentucky WC Medicaid |
$308.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$311.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
DOPPLER COLORFLOW VELOCITY MAP
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 93325
|
| Hospital Charge Code |
480P0110
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$152.50 |
| Rate for Payer: Aetna Commercial |
$88.67
|
| Rate for Payer: Ambetter Exchange |
$20.24
|
| Rate for Payer: Anthem Medicaid |
$83.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$20.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$20.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.29
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$152.50
|
| Rate for Payer: Healthspan PPO |
$83.34
|
| Rate for Payer: Humana Medicaid |
$83.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$20.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.89
|
| Rate for Payer: Molina Healthcare Passport |
$83.23
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$26.31
|
| Rate for Payer: UHCCP Medicaid |
$77.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.24
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Facility
|
OP
|
$864.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$259.20 |
| Max. Negotiated Rate |
$829.44 |
| Rate for Payer: Aetna Commercial |
$665.28
|
| Rate for Payer: Anthem Medicaid |
$297.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.92
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$717.12
|
| Rate for Payer: First Health Commercial |
$820.80
|
| Rate for Payer: Humana Commercial |
$734.40
|
| Rate for Payer: Humana KY Medicaid |
$297.13
|
| Rate for Payer: Kentucky WC Medicaid |
$300.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$708.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$637.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$259.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$303.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.32
|
| Rate for Payer: Ohio Health Group HMO |
$648.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$691.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$751.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$596.16
|
| Rate for Payer: PHCS Commercial |
$829.44
|
| Rate for Payer: United Healthcare All Payer |
$760.32
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$259.20 |
| Max. Negotiated Rate |
$829.44 |
| Rate for Payer: Aetna Commercial |
$665.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$673.92
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna Commercial |
$717.12
|
| Rate for Payer: First Health Commercial |
$820.80
|
| Rate for Payer: Humana Commercial |
$734.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$708.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$637.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$259.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.32
|
| Rate for Payer: Ohio Health Group HMO |
$648.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$691.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$751.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$596.16
|
| Rate for Payer: PHCS Commercial |
$829.44
|
| Rate for Payer: United Healthcare All Payer |
$760.32
|
|
|
DOPPLER ECHOCARDIOGRAPHY
|
Professional
|
Both
|
$864.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
48000108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$126.03
|
| Rate for Payer: Ambetter Exchange |
$45.37
|
| Rate for Payer: Anthem Medicaid |
$72.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.44
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$45.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.56
|
| Rate for Payer: Molina Healthcare Passport |
$72.12
|
| Rate for Payer: Multiplan PHCS |
$518.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$58.98
|
| Rate for Payer: UHCCP Medicaid |
$302.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.37
|
|
|
DOPPLER ECHOCRADIOGRAPHY
|
Professional
|
Both
|
$75.00
|
|
| Hospital Charge Code |
480P0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$52.50 |
| 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
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
480T0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$236.70 |
| Max. Negotiated Rate |
$757.44 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$236.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$631.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$686.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.41
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
DOPPLER ECHOCRADIOGRAPHY
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS 93320
|
| Hospital Charge Code |
480T0108
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$236.70 |
| Max. Negotiated Rate |
$757.44 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem Medicaid |
$271.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Humana KY Medicaid |
$271.34
|
| Rate for Payer: Kentucky WC Medicaid |
$274.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$236.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$276.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$631.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$686.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.41
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
DOPRAM (DOXAPRAM) 4 400MG/20ML
|
Facility
|
OP
|
$322.22
|
|
|
Service Code
|
NDC 641601801
|
| Hospital Charge Code |
25003028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.67 |
| 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 |
$257.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$280.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.33
|
| Rate for Payer: PHCS Commercial |
$309.33
|
| Rate for Payer: United Healthcare All Payer |
$283.55
|
|
|
DOPRAM (DOXAPRAM) 4 400MG/20ML
|
Facility
|
IP
|
$322.22
|
|
|
Service Code
|
NDC 641601801
|
| Hospital Charge Code |
25003028
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.67 |
| 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 |
$257.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$280.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.33
|
| Rate for Payer: PHCS Commercial |
$309.33
|
| Rate for Payer: United Healthcare All Payer |
$283.55
|
|
|
DOSIMETRY BASIC
|
Facility
|
IP
|
$574.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$172.20 |
| Max. Negotiated Rate |
$551.04 |
| Rate for Payer: Aetna Commercial |
$441.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$447.72
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cigna Commercial |
$476.42
|
| Rate for Payer: First Health Commercial |
$545.30
|
| Rate for Payer: Humana Commercial |
$487.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$470.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$423.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$505.12
|
| Rate for Payer: Ohio Health Group HMO |
$430.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.06
|
| Rate for Payer: PHCS Commercial |
$551.04
|
| Rate for Payer: United Healthcare All Payer |
$505.12
|
|
|
DOSIMETRY BASIC
|
Facility
|
OP
|
$574.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$551.04 |
| Rate for Payer: Aetna Commercial |
$441.98
|
| Rate for Payer: Anthem Medicaid |
$197.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$122.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$447.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$171.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.62
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cigna Commercial |
$476.42
|
| Rate for Payer: First Health Commercial |
$545.30
|
| Rate for Payer: Humana Commercial |
$487.90
|
| Rate for Payer: Humana KY Medicaid |
$197.40
|
| Rate for Payer: Humana Medicare Advantage |
$122.68
|
| Rate for Payer: Kentucky WC Medicaid |
$199.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$470.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$423.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$201.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$505.12
|
| Rate for Payer: Ohio Health Group HMO |
$430.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.06
|
| Rate for Payer: PHCS Commercial |
$551.04
|
| Rate for Payer: United Healthcare All Payer |
$505.12
|
|
|
DOSIMETRY BASIC
|
Professional
|
Both
|
$574.00
|
|
|
Service Code
|
HCPCS 77300
|
| Hospital Charge Code |
33300006
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$39.72 |
| Max. Negotiated Rate |
$344.40 |
| Rate for Payer: Aetna Commercial |
$110.34
|
| Rate for Payer: Ambetter Exchange |
$61.47
|
| Rate for Payer: Anthem Medicaid |
$62.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.76
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cash Price |
$287.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$61.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.21
|
| Rate for Payer: Molina Healthcare Passport |
$62.95
|
| Rate for Payer: Multiplan PHCS |
$344.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$79.91
|
| Rate for Payer: UHCCP Medicaid |
$200.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.47
|
|
|
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 |
$118.68 |
| Rate for Payer: Aetna Commercial |
$110.34
|
| Rate for Payer: Ambetter Exchange |
$61.47
|
| Rate for Payer: Anthem Medicaid |
$62.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$61.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$61.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$73.76
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$61.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.47
|
| 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 |
$79.91
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$61.47
|
|
