|
INFANT MYLICON GAS DROPS 15ML
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
25003783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
INFANT MYLICON GAS DROPS 15ML
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 62372063015
|
| Hospital Charge Code |
25003783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
INFANTS GAS RELIEF DROP (30ML)
|
Facility
|
OP
|
$4.99
|
|
|
Service Code
|
NDC 46122054703
|
| Hospital Charge Code |
25000780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Humana Commercial |
$4.24
|
| Rate for Payer: Humana KY Medicaid |
$1.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.39
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.55
|
| Rate for Payer: PHCS Commercial |
$4.79
|
| Rate for Payer: United Healthcare All Payer |
$4.39
|
| Rate for Payer: Aetna Commercial |
$3.84
|
| Rate for Payer: Anthem Medicaid |
$1.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.89
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.14
|
| Rate for Payer: First Health Commercial |
$4.74
|
|
|
INFANTS GAS RELIEF DROP (30ML)
|
Facility
|
IP
|
$4.99
|
|
|
Service Code
|
NDC 46122054703
|
| Hospital Charge Code |
25000780
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$4.79 |
| Rate for Payer: Aetna Commercial |
$3.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.89
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna Commercial |
$4.14
|
| Rate for Payer: First Health Commercial |
$4.74
|
| Rate for Payer: Humana Commercial |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.39
|
| Rate for Payer: Ohio Health Group HMO |
$3.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.55
|
| Rate for Payer: PHCS Commercial |
$4.79
|
| Rate for Payer: United Healthcare All Payer |
$4.39
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$11,611.63
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$7,879.32 |
| Max. Negotiated Rate |
$11,611.63 |
| Rate for Payer: Anthem Medicaid |
$7,879.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,294.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,611.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,196.93
|
| Rate for Payer: Humana KY Medicaid |
$7,879.32
|
| Rate for Payer: Humana Medicare Advantage |
$8,294.02
|
| Rate for Payer: Kentucky WC Medicaid |
$7,958.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,952.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,036.91
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$17,449.05
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$11,840.43 |
| Max. Negotiated Rate |
$17,449.05 |
| Rate for Payer: Anthem Medicaid |
$11,840.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12,463.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17,449.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$16,825.87
|
| Rate for Payer: Humana KY Medicaid |
$11,840.43
|
| Rate for Payer: Humana Medicare Advantage |
$12,463.61
|
| Rate for Payer: Kentucky WC Medicaid |
$11,958.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,956.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,077.24
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$7,559.38
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$5,129.58 |
| Max. Negotiated Rate |
$7,559.38 |
| Rate for Payer: Anthem Medicaid |
$5,129.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,399.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,559.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,289.41
|
| Rate for Payer: Humana KY Medicaid |
$5,129.58
|
| Rate for Payer: Humana Medicare Advantage |
$5,399.56
|
| Rate for Payer: Kentucky WC Medicaid |
$5,180.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,479.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,232.17
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$23,843.27
|
|
|
Service Code
|
MSDRG 854
|
| Min. Negotiated Rate |
$16,179.36 |
| Max. Negotiated Rate |
$23,843.27 |
| Rate for Payer: Anthem Medicaid |
$16,179.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,030.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,843.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,991.73
|
| Rate for Payer: Humana KY Medicaid |
$16,179.36
|
| Rate for Payer: Humana Medicare Advantage |
$17,030.91
|
| Rate for Payer: Kentucky WC Medicaid |
$16,341.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,437.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,502.95
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$58,482.84
|
|
|
Service Code
|
MSDRG 853
|
| Min. Negotiated Rate |
$39,684.79 |
| Max. Negotiated Rate |
$58,482.84 |
| Rate for Payer: Anthem Medicaid |
$39,684.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41,773.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$58,482.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$56,394.17
|
| Rate for Payer: Humana KY Medicaid |
$39,684.79
|
| Rate for Payer: Humana Medicare Advantage |
$41,773.46
|
| Rate for Payer: Kentucky WC Medicaid |
$40,081.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50,128.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$40,478.48
|
|
|
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,908.03
|
|
|
Service Code
|
MSDRG 855
|
| Min. Negotiated Rate |
$13,509.02 |
| Max. Negotiated Rate |
$19,908.03 |
| Rate for Payer: Anthem Medicaid |
$13,509.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,220.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,908.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$19,197.03
|
| Rate for Payer: Humana KY Medicaid |
$13,509.02
|
| Rate for Payer: Humana Medicare Advantage |
$14,220.02
|
| Rate for Payer: Kentucky WC Medicaid |
$13,644.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,064.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,779.20
|
|
|
INFED IRONDEX 50 MG/100MG/2ML
|
Facility
|
IP
|
$189.82
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
25002161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.68 |
| Max. Negotiated Rate |
$182.23 |
| Rate for Payer: Aetna Commercial |
$146.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.06
|
| Rate for Payer: Cash Price |
$94.91
|
| Rate for Payer: Cigna Commercial |
$157.55
|
| Rate for Payer: First Health Commercial |
$180.33
|
| Rate for Payer: Humana Commercial |
$161.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.04
|
| Rate for Payer: Ohio Health Group HMO |
$142.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.84
|
| Rate for Payer: PHCS Commercial |
$182.23
|
| Rate for Payer: United Healthcare All Payer |
$167.04
|
|
|
INFED IRONDEX 50 MG/100MG/2ML
|
Facility
|
OP
|
$189.82
|
|
|
Service Code
|
HCPCS J1750
|
| Hospital Charge Code |
25002161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.32 |
| Max. Negotiated Rate |
$182.23 |
| Rate for Payer: Aetna Commercial |
$146.16
|
| Rate for Payer: Anthem Medicaid |
$65.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.39
|
| Rate for Payer: Cash Price |
$94.91
|
| Rate for Payer: Cash Price |
$94.91
|
| Rate for Payer: Cigna Commercial |
$157.55
|
| Rate for Payer: First Health Commercial |
$180.33
|
| Rate for Payer: Humana Commercial |
$161.35
|
| Rate for Payer: Humana KY Medicaid |
$65.28
|
| Rate for Payer: Humana Medicare Advantage |
$17.32
|
| Rate for Payer: Kentucky WC Medicaid |
$65.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.04
|
| Rate for Payer: Ohio Health Group HMO |
$142.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.84
|
| Rate for Payer: PHCS Commercial |
$182.23
|
| Rate for Payer: United Healthcare All Payer |
$167.04
|
|
|
INFERIOR VENA CAVA LTD
|
Professional
|
Both
|
$915.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
40200027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.15 |
| Max. Negotiated Rate |
$915.00 |
| Rate for Payer: Aetna Commercial |
$169.22
|
| Rate for Payer: Anthem Medicaid |
$63.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$915.00
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$139.15
|
| Rate for Payer: Healthspan PPO |
$158.56
|
| Rate for Payer: Humana Medicaid |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.90
|
| Rate for Payer: Molina Healthcare Passport |
$63.63
|
| Rate for Payer: Multiplan PHCS |
$549.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$640.50
|
| Rate for Payer: UHCCP Medicaid |
$320.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.27
|
|
|
INFERIOR VENA CAVA LTD
|
Facility
|
IP
|
$915.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
40200027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$118.95 |
| Max. Negotiated Rate |
$878.40 |
| Rate for Payer: Aetna Commercial |
$704.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$713.70
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$759.45
|
| Rate for Payer: First Health Commercial |
$869.25
|
| Rate for Payer: Humana Commercial |
$777.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$750.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$675.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$805.20
|
| Rate for Payer: Ohio Health Group HMO |
$686.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.65
|
| Rate for Payer: PHCS Commercial |
$878.40
|
| Rate for Payer: United Healthcare All Payer |
$805.20
|
|
|
INFERIOR VENA CAVA LTD
|
Facility
|
OP
|
$915.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
40200027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$878.40 |
| Rate for Payer: Aetna Commercial |
$704.55
|
| Rate for Payer: Anthem Medicaid |
$314.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$713.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$759.45
|
| Rate for Payer: First Health Commercial |
$869.25
|
| Rate for Payer: Humana Commercial |
$777.75
|
| Rate for Payer: Humana KY Medicaid |
$314.67
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$317.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$750.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$675.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$320.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$805.20
|
| Rate for Payer: Ohio Health Group HMO |
$686.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$283.65
|
| Rate for Payer: PHCS Commercial |
$878.40
|
| Rate for Payer: United Healthcare All Payer |
$805.20
|
|
|
INFERIOR VENA CAVA LTD(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
402P0027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.15 |
| Max. Negotiated Rate |
$169.22 |
| Rate for Payer: Aetna Commercial |
$169.22
|
| Rate for Payer: Anthem Medicaid |
$63.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$139.15
|
| Rate for Payer: Healthspan PPO |
$158.56
|
| Rate for Payer: Humana Medicaid |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.90
|
| Rate for Payer: Molina Healthcare Passport |
$63.63
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.27
|
|
|
INFERIOR VENA CAVA LTD(T
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
402T0027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem Medicaid |
$271.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Humana KY Medicaid |
$271.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$274.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.90
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
INFERIOR VENA CAVA LTD(T
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS 76775
|
| Hospital Charge Code |
402T0027
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$102.70 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.90
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
INFERIOR VENOCAVAGRAM
|
Facility
|
IP
|
$4,770.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
32000167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$620.10 |
| Max. Negotiated Rate |
$4,579.20 |
| Rate for Payer: Aetna Commercial |
$3,672.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,720.60
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cigna Commercial |
$3,959.10
|
| Rate for Payer: First Health Commercial |
$4,531.50
|
| Rate for Payer: Humana Commercial |
$4,054.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,911.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,520.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,431.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,197.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$620.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.70
|
| Rate for Payer: PHCS Commercial |
$4,579.20
|
| Rate for Payer: United Healthcare All Payer |
$4,197.60
|
|
|
INFERIOR VENOCAVAGRAM
|
Facility
|
OP
|
$4,770.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
32000167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$620.10 |
| Max. Negotiated Rate |
$4,579.20 |
| Rate for Payer: Aetna Commercial |
$3,672.90
|
| Rate for Payer: Anthem Medicaid |
$1,640.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,720.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cigna Commercial |
$3,959.10
|
| Rate for Payer: First Health Commercial |
$4,531.50
|
| Rate for Payer: Humana Commercial |
$4,054.50
|
| Rate for Payer: Humana KY Medicaid |
$1,640.40
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,657.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,911.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,520.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,673.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,197.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,577.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$954.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$620.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.70
|
| Rate for Payer: PHCS Commercial |
$4,579.20
|
| Rate for Payer: United Healthcare All Payer |
$4,197.60
|
|
|
INFERIOR VENOCAVAGRAM
|
Professional
|
Both
|
$4,770.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
32000167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$72.45 |
| Max. Negotiated Rate |
$4,770.00 |
| Rate for Payer: Aetna Commercial |
$409.27
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,770.00
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cash Price |
$2,385.00
|
| Rate for Payer: Cigna Commercial |
$676.21
|
| Rate for Payer: Healthspan PPO |
$383.49
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$2,862.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,339.00
|
| Rate for Payer: UHCCP Medicaid |
$1,669.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
INFERIOR VENOCAVAGRAM(P
|
Professional
|
Both
|
$303.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
320P0167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$72.45 |
| Max. Negotiated Rate |
$676.21 |
| Rate for Payer: Aetna Commercial |
$409.27
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$303.00
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$676.21
|
| Rate for Payer: Healthspan PPO |
$383.49
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$181.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.10
|
| Rate for Payer: UHCCP Medicaid |
$106.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
INFERIOR VENOCAVAGRAM(T
|
Facility
|
OP
|
$4,467.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
320T0167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$580.71 |
| Max. Negotiated Rate |
$4,288.32 |
| Rate for Payer: Aetna Commercial |
$3,439.59
|
| Rate for Payer: Anthem Medicaid |
$1,536.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,484.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,233.50
|
| Rate for Payer: Cash Price |
$2,233.50
|
| Rate for Payer: Cigna Commercial |
$3,707.61
|
| Rate for Payer: First Health Commercial |
$4,243.65
|
| Rate for Payer: Humana Commercial |
$3,796.95
|
| Rate for Payer: Humana KY Medicaid |
$1,536.20
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,551.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,662.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,296.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,567.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,930.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,350.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,384.77
|
| Rate for Payer: PHCS Commercial |
$4,288.32
|
| Rate for Payer: United Healthcare All Payer |
$3,930.96
|
|
|
INFERIOR VENOCAVAGRAM(T
|
Facility
|
IP
|
$4,467.00
|
|
|
Service Code
|
HCPCS 75825
|
| Hospital Charge Code |
320T0167
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$580.71 |
| Max. Negotiated Rate |
$4,288.32 |
| Rate for Payer: Aetna Commercial |
$3,439.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,484.26
|
| Rate for Payer: Cash Price |
$2,233.50
|
| Rate for Payer: Cigna Commercial |
$3,707.61
|
| Rate for Payer: First Health Commercial |
$4,243.65
|
| Rate for Payer: Humana Commercial |
$3,796.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,662.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,296.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,340.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,930.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,350.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,384.77
|
| Rate for Payer: PHCS Commercial |
$4,288.32
|
| Rate for Payer: United Healthcare All Payer |
$3,930.96
|
|
|
INFINEON SPLITTER 2*8
|
Facility
|
IP
|
$7,180.00
|
|
|
Service Code
|
HCPCS C1883
|
| Hospital Charge Code |
27000063
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$933.40 |
| Max. Negotiated Rate |
$6,892.80 |
| Rate for Payer: Aetna Commercial |
$5,528.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,600.40
|
| Rate for Payer: Cash Price |
$3,590.00
|
| Rate for Payer: Cigna Commercial |
$5,959.40
|
| Rate for Payer: First Health Commercial |
$6,821.00
|
| Rate for Payer: Humana Commercial |
$6,103.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,887.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,298.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,154.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,318.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$933.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,225.80
|
| Rate for Payer: PHCS Commercial |
$6,892.80
|
| Rate for Payer: United Healthcare All Payer |
$6,318.40
|
|
