|
HYDRO SET INJCTBONE SUB CEM 10
|
Facility
|
IP
|
$13,924.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.22 |
| Max. Negotiated Rate |
$13,367.79 |
| Rate for Payer: Aetna Commercial |
$10,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,861.33
|
| Rate for Payer: Cash Price |
$6,962.39
|
| Rate for Payer: Cigna Commercial |
$11,557.57
|
| Rate for Payer: First Health Commercial |
$13,228.54
|
| Rate for Payer: Humana Commercial |
$11,836.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,418.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,276.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,177.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,253.81
|
| Rate for Payer: Ohio Health Group HMO |
$10,443.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,784.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,316.68
|
| Rate for Payer: PHCS Commercial |
$13,367.79
|
| Rate for Payer: United Healthcare All Payer |
$12,253.81
|
|
|
HYDRO SET INJCTBONE SUB CEM 10
|
Facility
|
OP
|
$13,924.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.22 |
| Max. Negotiated Rate |
$13,367.79 |
| Rate for Payer: Aetna Commercial |
$10,722.08
|
| Rate for Payer: Anthem Medicaid |
$4,788.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,861.33
|
| Rate for Payer: Cash Price |
$6,962.39
|
| Rate for Payer: Cigna Commercial |
$11,557.57
|
| Rate for Payer: First Health Commercial |
$13,228.54
|
| Rate for Payer: Humana Commercial |
$11,836.06
|
| Rate for Payer: Humana KY Medicaid |
$4,788.73
|
| Rate for Payer: Kentucky WC Medicaid |
$4,837.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,418.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,276.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,177.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,884.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,253.81
|
| Rate for Payer: Ohio Health Group HMO |
$10,443.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,784.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,316.68
|
| Rate for Payer: PHCS Commercial |
$13,367.79
|
| Rate for Payer: United Healthcare All Payer |
$12,253.81
|
|
|
HYDRO SET INJCT BONE SUB CEM15
|
Facility
|
IP
|
$20,075.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,609.78 |
| Max. Negotiated Rate |
$19,272.24 |
| Rate for Payer: Aetna Commercial |
$15,457.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,658.70
|
| Rate for Payer: Cash Price |
$10,037.62
|
| Rate for Payer: Cigna Commercial |
$16,662.46
|
| Rate for Payer: First Health Commercial |
$19,071.49
|
| Rate for Payer: Humana Commercial |
$17,063.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,461.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,815.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,022.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,666.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,056.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,609.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,223.33
|
| Rate for Payer: PHCS Commercial |
$19,272.24
|
| Rate for Payer: United Healthcare All Payer |
$17,666.22
|
|
|
HYDRO SET INJCT BONE SUB CEM15
|
Facility
|
OP
|
$20,075.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,609.78 |
| Max. Negotiated Rate |
$19,272.24 |
| Rate for Payer: Aetna Commercial |
$15,457.94
|
| Rate for Payer: Anthem Medicaid |
$6,903.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,658.70
|
| Rate for Payer: Cash Price |
$10,037.62
|
| Rate for Payer: Cigna Commercial |
$16,662.46
|
| Rate for Payer: First Health Commercial |
$19,071.49
|
| Rate for Payer: Humana Commercial |
$17,063.96
|
| Rate for Payer: Humana KY Medicaid |
$6,903.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6,974.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,461.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,815.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,022.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,042.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,666.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,056.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,609.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,223.33
|
| Rate for Payer: PHCS Commercial |
$19,272.24
|
| Rate for Payer: United Healthcare All Payer |
$17,666.22
|
|
|
HYDRO SET INJCT BONE SUB CEM 3
|
Facility
|
IP
|
$5,503.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$715.50 |
| Max. Negotiated Rate |
$5,283.67 |
| Rate for Payer: Aetna Commercial |
$4,237.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,292.98
|
| Rate for Payer: Cash Price |
$2,751.91
|
| Rate for Payer: Cigna Commercial |
$4,568.17
|
| Rate for Payer: First Health Commercial |
$5,228.63
|
| Rate for Payer: Humana Commercial |
$4,678.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,513.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,061.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,651.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,843.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,127.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.18
|
| Rate for Payer: PHCS Commercial |
$5,283.67
|
| Rate for Payer: United Healthcare All Payer |
$4,843.36
|
|
|
HYDRO SET INJCT BONE SUB CEM 3
|
Facility
|
OP
|
$5,503.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$715.50 |
| Max. Negotiated Rate |
$5,283.67 |
| Rate for Payer: Aetna Commercial |
$4,237.94
|
| Rate for Payer: Anthem Medicaid |
$1,892.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,292.98
|
| Rate for Payer: Cash Price |
$2,751.91
|
| Rate for Payer: Cigna Commercial |
$4,568.17
|
| Rate for Payer: First Health Commercial |
$5,228.63
|
| Rate for Payer: Humana Commercial |
$4,678.25
|
| Rate for Payer: Humana KY Medicaid |
$1,892.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1,912.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,513.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,061.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,651.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,930.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,843.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,127.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.18
|
| Rate for Payer: PHCS Commercial |
$5,283.67
|
| Rate for Payer: United Healthcare All Payer |
$4,843.36
|
|
|
HYDROSET XT INJ BNE SUB CEM 10
|
Facility
|
IP
|
$13,924.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.22 |
| Max. Negotiated Rate |
$13,367.79 |
| Rate for Payer: Aetna Commercial |
$10,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,861.33
|
| Rate for Payer: Cash Price |
$6,962.39
|
| Rate for Payer: Cigna Commercial |
$11,557.57
|
| Rate for Payer: First Health Commercial |
$13,228.54
|
| Rate for Payer: Humana Commercial |
$11,836.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,418.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,276.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,177.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,253.81
|
| Rate for Payer: Ohio Health Group HMO |
$10,443.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,784.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,316.68
|
| Rate for Payer: PHCS Commercial |
$13,367.79
|
| Rate for Payer: United Healthcare All Payer |
$12,253.81
|
|
|
HYDROSET XT INJ BNE SUB CEM 10
|
Facility
|
OP
|
$13,924.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,810.22 |
| Max. Negotiated Rate |
$13,367.79 |
| Rate for Payer: Aetna Commercial |
$10,722.08
|
| Rate for Payer: Anthem Medicaid |
$4,788.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,861.33
|
| Rate for Payer: Cash Price |
$6,962.39
|
| Rate for Payer: Cigna Commercial |
$11,557.57
|
| Rate for Payer: First Health Commercial |
$13,228.54
|
| Rate for Payer: Humana Commercial |
$11,836.06
|
| Rate for Payer: Humana KY Medicaid |
$4,788.73
|
| Rate for Payer: Kentucky WC Medicaid |
$4,837.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,418.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,276.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,177.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,884.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,253.81
|
| Rate for Payer: Ohio Health Group HMO |
$10,443.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,784.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,810.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,316.68
|
| Rate for Payer: PHCS Commercial |
$13,367.79
|
| Rate for Payer: United Healthcare All Payer |
$12,253.81
|
|
|
HYDROSET XT INJ BNESUB CEM15CC
|
Facility
|
IP
|
$20,075.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,609.78 |
| Max. Negotiated Rate |
$19,272.24 |
| Rate for Payer: Aetna Commercial |
$15,457.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,658.70
|
| Rate for Payer: Cash Price |
$10,037.62
|
| Rate for Payer: Cigna Commercial |
$16,662.46
|
| Rate for Payer: First Health Commercial |
$19,071.49
|
| Rate for Payer: Humana Commercial |
$17,063.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,461.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,815.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,022.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,666.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,056.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,609.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,223.33
|
| Rate for Payer: PHCS Commercial |
$19,272.24
|
| Rate for Payer: United Healthcare All Payer |
$17,666.22
|
|
|
HYDROSET XT INJ BNESUB CEM15CC
|
Facility
|
OP
|
$20,075.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,609.78 |
| Max. Negotiated Rate |
$19,272.24 |
| Rate for Payer: Aetna Commercial |
$15,457.94
|
| Rate for Payer: Anthem Medicaid |
$6,903.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,658.70
|
| Rate for Payer: Cash Price |
$10,037.62
|
| Rate for Payer: Cigna Commercial |
$16,662.46
|
| Rate for Payer: First Health Commercial |
$19,071.49
|
| Rate for Payer: Humana Commercial |
$17,063.96
|
| Rate for Payer: Humana KY Medicaid |
$6,903.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6,974.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,461.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,815.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,022.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,042.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,666.22
|
| Rate for Payer: Ohio Health Group HMO |
$15,056.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,609.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,223.33
|
| Rate for Payer: PHCS Commercial |
$19,272.24
|
| Rate for Payer: United Healthcare All Payer |
$17,666.22
|
|
|
HYDROSET XT INJ BNE SUB CEM 3C
|
Facility
|
IP
|
$5,503.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$715.50 |
| Max. Negotiated Rate |
$5,283.67 |
| Rate for Payer: Aetna Commercial |
$4,237.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,292.98
|
| Rate for Payer: Cash Price |
$2,751.91
|
| Rate for Payer: Cigna Commercial |
$4,568.17
|
| Rate for Payer: First Health Commercial |
$5,228.63
|
| Rate for Payer: Humana Commercial |
$4,678.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,513.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,061.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,651.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,843.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,127.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.18
|
| Rate for Payer: PHCS Commercial |
$5,283.67
|
| Rate for Payer: United Healthcare All Payer |
$4,843.36
|
|
|
HYDROSET XT INJ BNE SUB CEM 3C
|
Facility
|
OP
|
$5,503.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$715.50 |
| Max. Negotiated Rate |
$5,283.67 |
| Rate for Payer: Aetna Commercial |
$4,237.94
|
| Rate for Payer: Anthem Medicaid |
$1,892.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,292.98
|
| Rate for Payer: Cash Price |
$2,751.91
|
| Rate for Payer: Cigna Commercial |
$4,568.17
|
| Rate for Payer: First Health Commercial |
$5,228.63
|
| Rate for Payer: Humana Commercial |
$4,678.25
|
| Rate for Payer: Humana KY Medicaid |
$1,892.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1,912.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,513.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,061.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,651.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,930.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,843.36
|
| Rate for Payer: Ohio Health Group HMO |
$4,127.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,706.18
|
| Rate for Payer: PHCS Commercial |
$5,283.67
|
| Rate for Payer: United Healthcare All Payer |
$4,843.36
|
|
|
HYDROSET XT INJ BNE SUB CEM 5C
|
Facility
|
OP
|
$8,333.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.29 |
| Max. Negotiated Rate |
$7,999.71 |
| Rate for Payer: Aetna Commercial |
$6,416.43
|
| Rate for Payer: Anthem Medicaid |
$2,865.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,499.76
|
| Rate for Payer: Cash Price |
$4,166.52
|
| Rate for Payer: Cigna Commercial |
$6,916.41
|
| Rate for Payer: First Health Commercial |
$7,916.38
|
| Rate for Payer: Humana Commercial |
$7,083.08
|
| Rate for Payer: Humana KY Medicaid |
$2,865.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,894.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,833.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,149.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,499.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,923.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,333.07
|
| Rate for Payer: Ohio Health Group HMO |
$6,249.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,666.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,083.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,583.24
|
| Rate for Payer: PHCS Commercial |
$7,999.71
|
| Rate for Payer: United Healthcare All Payer |
$7,333.07
|
|
|
HYDROSET XT INJ BNE SUB CEM 5C
|
Facility
|
IP
|
$8,333.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,083.29 |
| Max. Negotiated Rate |
$7,999.71 |
| Rate for Payer: Aetna Commercial |
$6,416.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,499.76
|
| Rate for Payer: Cash Price |
$4,166.52
|
| Rate for Payer: Cigna Commercial |
$6,916.41
|
| Rate for Payer: First Health Commercial |
$7,916.38
|
| Rate for Payer: Humana Commercial |
$7,083.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,833.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,149.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,499.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,333.07
|
| Rate for Payer: Ohio Health Group HMO |
$6,249.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,666.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,083.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,583.24
|
| Rate for Payer: PHCS Commercial |
$7,999.71
|
| Rate for Payer: United Healthcare All Payer |
$7,333.07
|
|
|
HYDROXYZINE 25MG (100MG VIAL)
|
Facility
|
OP
|
$198.52
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
25002421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$152.86
|
| Rate for Payer: Anthem Medicaid |
$68.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.85
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cigna Commercial |
$164.77
|
| Rate for Payer: First Health Commercial |
$188.59
|
| Rate for Payer: Humana Commercial |
$168.74
|
| Rate for Payer: Humana KY Medicaid |
$68.27
|
| Rate for Payer: Kentucky WC Medicaid |
$68.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$162.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$174.70
|
| Rate for Payer: Ohio Health Group HMO |
$148.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.54
|
| Rate for Payer: PHCS Commercial |
$190.58
|
| Rate for Payer: United Healthcare All Payer |
$174.70
|
|
|
HYDROXYZINE 25MG (100MG VIAL)
|
Facility
|
IP
|
$198.52
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
25002421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$190.58 |
| Rate for Payer: Aetna Commercial |
$152.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.85
|
| Rate for Payer: Cash Price |
$99.26
|
| Rate for Payer: Cigna Commercial |
$164.77
|
| Rate for Payer: First Health Commercial |
$188.59
|
| Rate for Payer: Humana Commercial |
$168.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$162.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$174.70
|
| Rate for Payer: Ohio Health Group HMO |
$148.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.54
|
| Rate for Payer: PHCS Commercial |
$190.58
|
| Rate for Payer: United Healthcare All Payer |
$174.70
|
|
|
HYDROXYZINE 25MG (50MG VIAL)
|
Facility
|
OP
|
$168.24
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
25002422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$161.51 |
| Rate for Payer: Aetna Commercial |
$129.54
|
| Rate for Payer: Anthem Medicaid |
$57.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.23
|
| Rate for Payer: Cash Price |
$84.12
|
| Rate for Payer: Cigna Commercial |
$139.64
|
| Rate for Payer: First Health Commercial |
$159.83
|
| Rate for Payer: Humana Commercial |
$143.00
|
| Rate for Payer: Humana KY Medicaid |
$57.86
|
| Rate for Payer: Kentucky WC Medicaid |
$58.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.05
|
| Rate for Payer: Ohio Health Group HMO |
$126.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.15
|
| Rate for Payer: PHCS Commercial |
$161.51
|
| Rate for Payer: United Healthcare All Payer |
$148.05
|
|
|
HYDROXYZINE 25MG (50MG VIAL)
|
Facility
|
IP
|
$168.24
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
25002422
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.87 |
| Max. Negotiated Rate |
$161.51 |
| Rate for Payer: Aetna Commercial |
$129.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.23
|
| Rate for Payer: Cash Price |
$84.12
|
| Rate for Payer: Cigna Commercial |
$139.64
|
| Rate for Payer: First Health Commercial |
$159.83
|
| Rate for Payer: Humana Commercial |
$143.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.05
|
| Rate for Payer: Ohio Health Group HMO |
$126.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.15
|
| Rate for Payer: PHCS Commercial |
$161.51
|
| Rate for Payer: United Healthcare All Payer |
$148.05
|
|
|
HYGROTON 25MG TABLET
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
NDC 378022201
|
| Hospital Charge Code |
25000765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.03
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.29
|
| Rate for Payer: First Health Commercial |
$4.91
|
| Rate for Payer: Humana Commercial |
$4.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.55
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.96
|
| Rate for Payer: United Healthcare All Payer |
$4.55
|
|
|
HYGROTON 25MG TABLET
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 378022201
|
| Hospital Charge Code |
25000765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.03
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.29
|
| Rate for Payer: First Health Commercial |
$4.91
|
| Rate for Payer: Humana Commercial |
$4.39
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.55
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.96
|
| Rate for Payer: United Healthcare All Payer |
$4.55
|
|
|
HYLENEX 1unit (150unit SDV)
|
Facility
|
OP
|
$304.11
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
25004348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.53 |
| Max. Negotiated Rate |
$291.95 |
| Rate for Payer: Aetna Commercial |
$234.16
|
| Rate for Payer: Anthem Medicaid |
$104.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.21
|
| Rate for Payer: Cash Price |
$152.06
|
| Rate for Payer: Cigna Commercial |
$252.41
|
| Rate for Payer: First Health Commercial |
$288.90
|
| Rate for Payer: Humana Commercial |
$258.49
|
| Rate for Payer: Humana KY Medicaid |
$104.58
|
| Rate for Payer: Kentucky WC Medicaid |
$105.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.62
|
| Rate for Payer: Ohio Health Group HMO |
$228.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.27
|
| Rate for Payer: PHCS Commercial |
$291.95
|
| Rate for Payer: United Healthcare All Payer |
$267.62
|
|
|
HYLENEX 1unit (150unit SDV)
|
Facility
|
IP
|
$304.11
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
25004348
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.53 |
| Max. Negotiated Rate |
$291.95 |
| Rate for Payer: Aetna Commercial |
$234.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.21
|
| Rate for Payer: Cash Price |
$152.06
|
| Rate for Payer: Cigna Commercial |
$252.41
|
| Rate for Payer: First Health Commercial |
$288.90
|
| Rate for Payer: Humana Commercial |
$258.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.62
|
| Rate for Payer: Ohio Health Group HMO |
$228.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.27
|
| Rate for Payer: PHCS Commercial |
$291.95
|
| Rate for Payer: United Healthcare All Payer |
$267.62
|
|
|
HYOSCYAMINE 0.25mg (0.5mg SDV)
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
25002214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem Medicaid |
$115.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Humana KY Medicaid |
$115.21
|
| Rate for Payer: Kentucky WC Medicaid |
$116.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
HYOSCYAMINE 0.25mg (0.5mg SDV)
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
25002214
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
HYPERRAB 150 IU (1500 U VIAL)
|
Facility
|
IP
|
$18,543.46
|
|
|
Service Code
|
HCPCS 90375
|
| Hospital Charge Code |
25000007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,410.65 |
| Max. Negotiated Rate |
$17,801.72 |
| Rate for Payer: Aetna Commercial |
$14,278.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,463.90
|
| Rate for Payer: Cash Price |
$9,271.73
|
| Rate for Payer: Cigna Commercial |
$15,391.07
|
| Rate for Payer: First Health Commercial |
$17,616.29
|
| Rate for Payer: Humana Commercial |
$15,761.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,205.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,685.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,318.24
|
| Rate for Payer: Ohio Health Group HMO |
$13,907.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,708.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,410.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,748.47
|
| Rate for Payer: PHCS Commercial |
$17,801.72
|
| Rate for Payer: United Healthcare All Payer |
$16,318.24
|
|
