|
DUP SCAN OF UPPER EXT ARTERIES
|
Professional
|
Both
|
$587.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
92100009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$30.89 |
| Max. Negotiated Rate |
$352.20 |
| Rate for Payer: Aetna Commercial |
$270.01
|
| Rate for Payer: Ambetter Exchange |
$176.60
|
| Rate for Payer: Anthem Medicaid |
$137.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$176.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$176.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$211.92
|
| Rate for Payer: Cash Price |
$293.50
|
| Rate for Payer: Cash Price |
$293.50
|
| Rate for Payer: Cigna Commercial |
$306.90
|
| Rate for Payer: Healthspan PPO |
$288.43
|
| Rate for Payer: Humana Medicaid |
$137.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$176.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$176.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.77
|
| Rate for Payer: Molina Healthcare Passport |
$137.03
|
| Rate for Payer: Multiplan PHCS |
$352.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$229.58
|
| Rate for Payer: UHCCP Medicaid |
$205.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$176.60
|
|
|
DUP SCAN OF UPPER EXT ARTERIES
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 93930
|
| Hospital Charge Code |
921T0009
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem Medicaid |
$273.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Humana KY Medicaid |
$273.40
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$276.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921T0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921T0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Professional
|
Both
|
$795.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$477.00 |
| Rate for Payer: Aetna Commercial |
$173.24
|
| Rate for Payer: Ambetter Exchange |
$109.53
|
| Rate for Payer: Anthem Medicaid |
$91.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$109.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$109.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$131.44
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$202.24
|
| Rate for Payer: Healthspan PPO |
$185.06
|
| Rate for Payer: Humana Medicaid |
$91.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$109.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.01
|
| Rate for Payer: Molina Healthcare Passport |
$91.19
|
| Rate for Payer: Multiplan PHCS |
$477.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$142.39
|
| Rate for Payer: UHCCP Medicaid |
$278.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$109.53
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
921P0010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$20.92 |
| Max. Negotiated Rate |
$202.24 |
| Rate for Payer: Aetna Commercial |
$173.24
|
| Rate for Payer: Ambetter Exchange |
$109.53
|
| Rate for Payer: Anthem Medicaid |
$91.19
|
| Rate for Payer: Buckeye Individual/Medicaid |
$109.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$109.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$131.44
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$202.24
|
| Rate for Payer: Healthspan PPO |
$185.06
|
| Rate for Payer: Humana Medicaid |
$91.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$109.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.01
|
| Rate for Payer: Molina Healthcare Passport |
$91.19
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$142.39
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$92.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$109.53
|
|
|
DUP SCAN UPPER EXT ART. LIMITE
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS 93931
|
| Hospital Charge Code |
92100010
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
DURACLON [1MG] 1MG/10ML VIAL
|
Facility
|
OP
|
$187.34
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
25001961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Anthem Medicaid |
$64.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.13
|
| Rate for Payer: Cash Price |
$93.67
|
| Rate for Payer: Cigna Commercial |
$155.49
|
| Rate for Payer: First Health Commercial |
$177.97
|
| Rate for Payer: Humana Commercial |
$159.24
|
| Rate for Payer: Humana KY Medicaid |
$64.43
|
| Rate for Payer: Kentucky WC Medicaid |
$65.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.86
|
| Rate for Payer: Ohio Health Group HMO |
$140.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.26
|
| Rate for Payer: PHCS Commercial |
$179.85
|
| Rate for Payer: United Healthcare All Payer |
$164.86
|
|
|
DURACLON [1MG] 1MG/10ML VIAL
|
Facility
|
IP
|
$187.34
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
25001961
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$179.85 |
| Rate for Payer: Aetna Commercial |
$144.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.13
|
| Rate for Payer: Cash Price |
$93.67
|
| Rate for Payer: Cigna Commercial |
$155.49
|
| Rate for Payer: First Health Commercial |
$177.97
|
| Rate for Payer: Humana Commercial |
$159.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.86
|
| Rate for Payer: Ohio Health Group HMO |
$140.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.26
|
| Rate for Payer: PHCS Commercial |
$179.85
|
| Rate for Payer: United Healthcare All Payer |
$164.86
|
|
|
DURAGESIC PTCH 12MCCG/FENTANYL
|
Facility
|
OP
|
$76.24
|
|
|
Service Code
|
NDC 406911276
|
| Hospital Charge Code |
25000586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$73.19 |
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem Medicaid |
$26.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.47
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.28
|
| Rate for Payer: First Health Commercial |
$72.43
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Humana KY Medicaid |
$26.22
|
| Rate for Payer: Kentucky WC Medicaid |
$26.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.09
|
| Rate for Payer: Ohio Health Group HMO |
$57.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.61
|
| Rate for Payer: PHCS Commercial |
$73.19
|
| Rate for Payer: United Healthcare All Payer |
$67.09
|
|
|
DURAGESIC PTCH 12MCCG/FENTANYL
|
Facility
|
IP
|
$76.24
|
|
|
Service Code
|
NDC 406911276
|
| Hospital Charge Code |
25000586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$73.19 |
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.47
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.28
|
| Rate for Payer: First Health Commercial |
$72.43
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.09
|
| Rate for Payer: Ohio Health Group HMO |
$57.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.61
|
| Rate for Payer: PHCS Commercial |
$73.19
|
| Rate for Payer: United Healthcare All Payer |
$67.09
|
|
|
DURALOC LOCK RING 58MM
|
Facility
|
OP
|
$3,995.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,198.61 |
| Max. Negotiated Rate |
$3,835.56 |
| Rate for Payer: Aetna Commercial |
$3,076.44
|
| Rate for Payer: Anthem Medicaid |
$1,374.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,116.40
|
| Rate for Payer: Cash Price |
$1,997.69
|
| Rate for Payer: Cigna Commercial |
$3,316.17
|
| Rate for Payer: First Health Commercial |
$3,795.61
|
| Rate for Payer: Humana Commercial |
$3,396.07
|
| Rate for Payer: Humana KY Medicaid |
$1,374.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,388.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,276.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,948.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,198.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,401.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,515.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,996.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,196.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,475.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,756.81
|
| Rate for Payer: PHCS Commercial |
$3,835.56
|
| Rate for Payer: United Healthcare All Payer |
$3,515.93
|
|
|
DURALOC LOCK RING 58MM
|
Facility
|
IP
|
$3,995.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,198.61 |
| Max. Negotiated Rate |
$3,835.56 |
| Rate for Payer: Aetna Commercial |
$3,076.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,116.40
|
| Rate for Payer: Cash Price |
$1,997.69
|
| Rate for Payer: Cigna Commercial |
$3,316.17
|
| Rate for Payer: First Health Commercial |
$3,795.61
|
| Rate for Payer: Humana Commercial |
$3,396.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,276.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,948.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,198.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,515.93
|
| Rate for Payer: Ohio Health Group HMO |
$2,996.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,196.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,475.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,756.81
|
| Rate for Payer: PHCS Commercial |
$3,835.56
|
| Rate for Payer: United Healthcare All Payer |
$3,515.93
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$6,076.75
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
25003974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,823.03 |
| Max. Negotiated Rate |
$5,833.68 |
| Rate for Payer: Aetna Commercial |
$4,679.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,739.86
|
| Rate for Payer: Cash Price |
$3,038.38
|
| Rate for Payer: Cigna Commercial |
$5,043.70
|
| Rate for Payer: First Health Commercial |
$5,772.91
|
| Rate for Payer: Humana Commercial |
$5,165.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,982.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,484.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,823.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,347.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,557.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,861.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,286.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,192.96
|
| Rate for Payer: PHCS Commercial |
$5,833.68
|
| Rate for Payer: United Healthcare All Payer |
$5,347.54
|
|
|
DUROLANE 1mg (60mg)
|
Professional
|
Both
|
$101.28
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$60.77 |
| Rate for Payer: Aetna Commercial |
$21.34
|
| Rate for Payer: Ambetter Exchange |
$6.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$6.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$6.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.02
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Multiplan PHCS |
$60.77
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8.68
|
| Rate for Payer: UHCCP Medicaid |
$35.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$6.68
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$101.28
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
636T0118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$97.23 |
| Rate for Payer: Aetna Commercial |
$77.99
|
| Rate for Payer: Anthem Medicaid |
$34.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cigna Commercial |
$84.06
|
| Rate for Payer: First Health Commercial |
$96.22
|
| Rate for Payer: Humana Commercial |
$86.09
|
| Rate for Payer: Humana KY Medicaid |
$34.83
|
| Rate for Payer: Humana Medicare Advantage |
$6.68
|
| Rate for Payer: Kentucky WC Medicaid |
$35.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.13
|
| Rate for Payer: Ohio Health Group HMO |
$75.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.88
|
| Rate for Payer: PHCS Commercial |
$97.23
|
| Rate for Payer: United Healthcare All Payer |
$89.13
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$6,076.75
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
25003974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$5,833.68 |
| Rate for Payer: Aetna Commercial |
$4,679.10
|
| Rate for Payer: Anthem Medicaid |
$2,089.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,739.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$3,038.38
|
| Rate for Payer: Cash Price |
$3,038.38
|
| Rate for Payer: Cigna Commercial |
$5,043.70
|
| Rate for Payer: First Health Commercial |
$5,772.91
|
| Rate for Payer: Humana Commercial |
$5,165.24
|
| Rate for Payer: Humana KY Medicaid |
$2,089.79
|
| Rate for Payer: Humana Medicare Advantage |
$6.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,111.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,982.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,484.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,131.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,347.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,557.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,861.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,286.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,192.96
|
| Rate for Payer: PHCS Commercial |
$5,833.68
|
| Rate for Payer: United Healthcare All Payer |
$5,347.54
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
OP
|
$101.28
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$97.23 |
| Rate for Payer: Aetna Commercial |
$77.99
|
| Rate for Payer: Anthem Medicaid |
$34.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cigna Commercial |
$84.06
|
| Rate for Payer: First Health Commercial |
$96.22
|
| Rate for Payer: Humana Commercial |
$86.09
|
| Rate for Payer: Humana KY Medicaid |
$34.83
|
| Rate for Payer: Humana Medicare Advantage |
$6.68
|
| Rate for Payer: Kentucky WC Medicaid |
$35.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.13
|
| Rate for Payer: Ohio Health Group HMO |
$75.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.88
|
| Rate for Payer: PHCS Commercial |
$97.23
|
| Rate for Payer: United Healthcare All Payer |
$89.13
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$101.28
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$97.23 |
| Rate for Payer: Aetna Commercial |
$77.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cigna Commercial |
$84.06
|
| Rate for Payer: First Health Commercial |
$96.22
|
| Rate for Payer: Humana Commercial |
$86.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.13
|
| Rate for Payer: Ohio Health Group HMO |
$75.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.88
|
| Rate for Payer: PHCS Commercial |
$97.23
|
| Rate for Payer: United Healthcare All Payer |
$89.13
|
|
|
DUROLANE 1mg (60mg)
|
Facility
|
IP
|
$101.28
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
636T0118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$97.23 |
| Rate for Payer: Aetna Commercial |
$77.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$50.64
|
| Rate for Payer: Cigna Commercial |
$84.06
|
| Rate for Payer: First Health Commercial |
$96.22
|
| Rate for Payer: Humana Commercial |
$86.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$83.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.13
|
| Rate for Payer: Ohio Health Group HMO |
$75.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.88
|
| Rate for Payer: PHCS Commercial |
$97.23
|
| Rate for Payer: United Healthcare All Payer |
$89.13
|
|
|
DVX CATHETER
|
Facility
|
IP
|
$7,580.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,274.22 |
| Max. Negotiated Rate |
$7,277.52 |
| Rate for Payer: Aetna Commercial |
$5,837.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,912.98
|
| Rate for Payer: Cash Price |
$3,790.38
|
| Rate for Payer: Cigna Commercial |
$6,292.02
|
| Rate for Payer: First Health Commercial |
$7,201.71
|
| Rate for Payer: Humana Commercial |
$6,443.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,216.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,594.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,274.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,671.06
|
| Rate for Payer: Ohio Health Group HMO |
$5,685.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,064.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,595.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,230.72
|
| Rate for Payer: PHCS Commercial |
$7,277.52
|
| Rate for Payer: United Healthcare All Payer |
$6,671.06
|
|
|
DVX CATHETER
|
Facility
|
OP
|
$7,580.75
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,274.22 |
| Max. Negotiated Rate |
$7,277.52 |
| Rate for Payer: Aetna Commercial |
$5,837.18
|
| Rate for Payer: Anthem Medicaid |
$2,607.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,912.98
|
| Rate for Payer: Cash Price |
$3,790.38
|
| Rate for Payer: Cigna Commercial |
$6,292.02
|
| Rate for Payer: First Health Commercial |
$7,201.71
|
| Rate for Payer: Humana Commercial |
$6,443.64
|
| Rate for Payer: Humana KY Medicaid |
$2,607.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,633.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,216.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,594.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,274.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,659.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,671.06
|
| Rate for Payer: Ohio Health Group HMO |
$5,685.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,064.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,595.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,230.72
|
| Rate for Payer: PHCS Commercial |
$7,277.52
|
| Rate for Payer: United Healthcare All Payer |
$6,671.06
|
|
|
DX BRONCHOSCOPE/BRUSH
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS 31623
|
| Hospital Charge Code |
41000035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$66.97 |
| Max. Negotiated Rate |
$417.03 |
| Rate for Payer: Aetna Commercial |
$243.94
|
| Rate for Payer: Ambetter Exchange |
$122.81
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.97
|
| Rate for Payer: Anthem Medicaid |
$181.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.37
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$222.18
|
| Rate for Payer: Healthspan PPO |
$417.03
|
| Rate for Payer: Humana Medicaid |
$181.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$188.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$184.79
|
| Rate for Payer: Molina Healthcare Passport |
$181.17
|
| Rate for Payer: Multiplan PHCS |
$222.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.65
|
| Rate for Payer: UHCCP Medicaid |
$70.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$182.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.81
|
|
|
DX BRONCHOSCOPE/BRUSH
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
HCPCS 31623
|
| Hospital Charge Code |
41000035
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$2,230.73 |
| Rate for Payer: Aetna Commercial |
$285.67
|
| Rate for Payer: Anthem Medicaid |
$127.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,593.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$289.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,230.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,151.06
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$307.93
|
| Rate for Payer: First Health Commercial |
$352.45
|
| Rate for Payer: Humana Commercial |
$315.35
|
| Rate for Payer: Humana KY Medicaid |
$127.59
|
| Rate for Payer: Humana Medicare Advantage |
$1,593.38
|
| Rate for Payer: Kentucky WC Medicaid |
$128.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$304.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,912.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$326.48
|
| Rate for Payer: Ohio Health Group HMO |
$278.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$322.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.99
|
| Rate for Payer: PHCS Commercial |
$356.16
|
| Rate for Payer: United Healthcare All Payer |
$326.48
|
|
