|
HYSTROSCOPE SHEATH 15FR OVAL
|
Facility
|
OP
|
$4,448.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,334.40 |
| Max. Negotiated Rate |
$4,270.08 |
| Rate for Payer: Aetna Commercial |
$3,424.96
|
| Rate for Payer: Anthem Medicaid |
$1,529.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,469.44
|
| Rate for Payer: Cash Price |
$2,224.00
|
| Rate for Payer: Cigna Commercial |
$3,691.84
|
| Rate for Payer: First Health Commercial |
$4,225.60
|
| Rate for Payer: Humana Commercial |
$3,780.80
|
| Rate for Payer: Humana KY Medicaid |
$1,529.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,545.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,647.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,282.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,334.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,560.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,914.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,336.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,558.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,869.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,069.12
|
| Rate for Payer: PHCS Commercial |
$4,270.08
|
| Rate for Payer: United Healthcare All Payer |
$3,914.24
|
|
|
HYTRIN (TERAZOSIN) 1 1MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 378226001
|
| Hospital Charge Code |
25000766
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
HYTRIN (TERAZOSIN) 1 1MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 378226001
|
| Hospital Charge Code |
25000766
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
HYTRIN (TERAZOSIN) 2 2MG/1TAB
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 50268076515
|
| Hospital Charge Code |
25000767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
HYTRIN (TERAZOSIN) 2 2MG/1TAB
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 50268076515
|
| Hospital Charge Code |
25000767
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
HYTRIN (TERAZOSIN) 5 5MG/1TAB
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 59746038506
|
| Hospital Charge Code |
25000768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
HYTRIN (TERAZOSIN) 5 5MG/1TAB
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 59746038506
|
| Hospital Charge Code |
25000768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
HZV VACC RECOMBINANT IM
|
Facility
|
IP
|
$542.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
77000055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.60 |
| Max. Negotiated Rate |
$520.32 |
| Rate for Payer: Aetna Commercial |
$417.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.76
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Cigna Commercial |
$449.86
|
| Rate for Payer: First Health Commercial |
$514.90
|
| Rate for Payer: Humana Commercial |
$460.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.96
|
| Rate for Payer: Ohio Health Group HMO |
$406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$373.98
|
| Rate for Payer: PHCS Commercial |
$520.32
|
| Rate for Payer: United Healthcare All Payer |
$476.96
|
|
|
HZV VACC RECOMBINANT IM
|
Professional
|
Both
|
$542.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
77000055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.70 |
| Max. Negotiated Rate |
$379.40 |
| Rate for Payer: Anthem Medicaid |
$280.00
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Humana Medicaid |
$280.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$264.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$285.60
|
| Rate for Payer: Molina Healthcare Passport |
$280.00
|
| Rate for Payer: Multiplan PHCS |
$325.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$379.40
|
| Rate for Payer: UHCCP Medicaid |
$189.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$282.80
|
|
|
HZV VACC RECOMBINANT IM
|
Facility
|
OP
|
$542.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
77000055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.60 |
| Max. Negotiated Rate |
$520.32 |
| Rate for Payer: Aetna Commercial |
$417.34
|
| Rate for Payer: Anthem Medicaid |
$186.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.76
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Cigna Commercial |
$449.86
|
| Rate for Payer: First Health Commercial |
$514.90
|
| Rate for Payer: Humana Commercial |
$460.70
|
| Rate for Payer: Humana KY Medicaid |
$186.39
|
| Rate for Payer: Kentucky WC Medicaid |
$188.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.96
|
| Rate for Payer: Ohio Health Group HMO |
$406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$373.98
|
| Rate for Payer: PHCS Commercial |
$520.32
|
| Rate for Payer: United Healthcare All Payer |
$476.96
|
|
|
HZV VACC RECOMBINANT IM(T
|
Facility
|
OP
|
$542.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
770T0055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.60 |
| Max. Negotiated Rate |
$520.32 |
| Rate for Payer: Aetna Commercial |
$417.34
|
| Rate for Payer: Anthem Medicaid |
$186.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.76
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Cigna Commercial |
$449.86
|
| Rate for Payer: First Health Commercial |
$514.90
|
| Rate for Payer: Humana Commercial |
$460.70
|
| Rate for Payer: Humana KY Medicaid |
$186.39
|
| Rate for Payer: Kentucky WC Medicaid |
$188.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.96
|
| Rate for Payer: Ohio Health Group HMO |
$406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$373.98
|
| Rate for Payer: PHCS Commercial |
$520.32
|
| Rate for Payer: United Healthcare All Payer |
$476.96
|
|
|
HZV VACC RECOMBINANT IM(T
|
Facility
|
IP
|
$542.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
770T0055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.60 |
| Max. Negotiated Rate |
$520.32 |
| Rate for Payer: Aetna Commercial |
$417.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$422.76
|
| Rate for Payer: Cash Price |
$271.00
|
| Rate for Payer: Cigna Commercial |
$449.86
|
| Rate for Payer: First Health Commercial |
$514.90
|
| Rate for Payer: Humana Commercial |
$460.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$444.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.96
|
| Rate for Payer: Ohio Health Group HMO |
$406.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$373.98
|
| Rate for Payer: PHCS Commercial |
$520.32
|
| Rate for Payer: United Healthcare All Payer |
$476.96
|
|
|
I 123 SOD IODIDE PER 100 UCI 1
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
340T0052
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
|
I 123 SOD IODIDE PER 100 UCI 1
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
34000052
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem Medicaid |
$71.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Humana KY Medicaid |
$71.19
|
| Rate for Payer: Kentucky WC Medicaid |
$71.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
|
I 123 SOD IODIDE PER 100 UCI 1
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
34000052
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
|
I 123 SOD IODIDE PER 100 UCI 1
|
Professional
|
Both
|
$207.00
|
|
| Hospital Charge Code |
34000052
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$72.45 |
| Max. Negotiated Rate |
$144.90 |
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Multiplan PHCS |
$124.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.90
|
| Rate for Payer: UHCCP Medicaid |
$72.45
|
|
|
I 123 SOD IODIDE PER 100 UCI 1
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
HCPCS A9516
|
| Hospital Charge Code |
340T0052
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem Medicaid |
$71.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Humana KY Medicaid |
$71.19
|
| Rate for Payer: Kentucky WC Medicaid |
$71.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
|
I-131 THYROID (ABLATN GLAND)
|
Facility
|
IP
|
$1,091.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
34000044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$327.30 |
| Max. Negotiated Rate |
$1,047.36 |
| Rate for Payer: Aetna Commercial |
$840.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$850.98
|
| Rate for Payer: Cash Price |
$545.50
|
| Rate for Payer: Cigna Commercial |
$905.53
|
| Rate for Payer: First Health Commercial |
$1,036.45
|
| Rate for Payer: Humana Commercial |
$927.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$894.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$805.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$960.08
|
| Rate for Payer: Ohio Health Group HMO |
$818.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$872.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$949.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$752.79
|
| Rate for Payer: PHCS Commercial |
$1,047.36
|
| Rate for Payer: United Healthcare All Payer |
$960.08
|
|
|
I-131 THYROID (ABLATN GLAND)
|
Professional
|
Both
|
$1,091.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
34000044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$99.37 |
| Max. Negotiated Rate |
$654.60 |
| Rate for Payer: Aetna Commercial |
$239.47
|
| Rate for Payer: Ambetter Exchange |
$124.59
|
| Rate for Payer: Anthem Medicaid |
$141.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$124.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$124.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.51
|
| Rate for Payer: Cash Price |
$545.50
|
| Rate for Payer: Cash Price |
$545.50
|
| Rate for Payer: Cigna Commercial |
$265.27
|
| Rate for Payer: Healthspan PPO |
$239.34
|
| Rate for Payer: Humana Medicaid |
$141.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$124.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.10
|
| Rate for Payer: Molina Healthcare Passport |
$141.27
|
| Rate for Payer: Multiplan PHCS |
$654.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.97
|
| Rate for Payer: UHCCP Medicaid |
$381.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$124.59
|
|
|
I-131 THYROID (ABLATN GLAND)
|
Facility
|
OP
|
$1,091.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
34000044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$207.09 |
| Max. Negotiated Rate |
$1,047.36 |
| Rate for Payer: Aetna Commercial |
$840.07
|
| Rate for Payer: Anthem Medicaid |
$375.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$207.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$850.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$289.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$279.57
|
| Rate for Payer: Cash Price |
$545.50
|
| Rate for Payer: Cash Price |
$545.50
|
| Rate for Payer: Cigna Commercial |
$905.53
|
| Rate for Payer: First Health Commercial |
$1,036.45
|
| Rate for Payer: Humana Commercial |
$927.35
|
| Rate for Payer: Humana KY Medicaid |
$375.19
|
| Rate for Payer: Humana Medicare Advantage |
$207.09
|
| Rate for Payer: Kentucky WC Medicaid |
$379.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$894.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$805.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$248.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$382.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$960.08
|
| Rate for Payer: Ohio Health Group HMO |
$818.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$872.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$949.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$752.79
|
| Rate for Payer: PHCS Commercial |
$1,047.36
|
| Rate for Payer: United Healthcare All Payer |
$960.08
|
|
|
I-131 THYROID (ABLATN GLAND)(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
340P0044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$99.37 |
| Max. Negotiated Rate |
$265.27 |
| Rate for Payer: Aetna Commercial |
$239.47
|
| Rate for Payer: Ambetter Exchange |
$124.59
|
| Rate for Payer: Anthem Medicaid |
$141.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$124.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$124.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.51
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$265.27
|
| Rate for Payer: Healthspan PPO |
$239.34
|
| Rate for Payer: Humana Medicaid |
$141.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$124.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.10
|
| Rate for Payer: Molina Healthcare Passport |
$141.27
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.97
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$124.59
|
|
|
I-131 THYROID (ABLATN GLAND)(T
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
340T0044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$237.30 |
| Max. Negotiated Rate |
$759.36 |
| Rate for Payer: Aetna Commercial |
$609.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.98
|
| Rate for Payer: Cash Price |
$395.50
|
| Rate for Payer: Cigna Commercial |
$656.53
|
| Rate for Payer: First Health Commercial |
$751.45
|
| Rate for Payer: Humana Commercial |
$672.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$648.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$696.08
|
| Rate for Payer: Ohio Health Group HMO |
$593.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$688.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.79
|
| Rate for Payer: PHCS Commercial |
$759.36
|
| Rate for Payer: United Healthcare All Payer |
$696.08
|
|
|
I-131 THYROID (ABLATN GLAND)(T
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 79005
|
| Hospital Charge Code |
340T0044
|
|
Hospital Revenue Code
|
342
|
| Min. Negotiated Rate |
$207.09 |
| Max. Negotiated Rate |
$759.36 |
| Rate for Payer: Aetna Commercial |
$609.07
|
| Rate for Payer: Anthem Medicaid |
$272.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$207.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$289.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$279.57
|
| Rate for Payer: Cash Price |
$395.50
|
| Rate for Payer: Cash Price |
$395.50
|
| Rate for Payer: Cigna Commercial |
$656.53
|
| Rate for Payer: First Health Commercial |
$751.45
|
| Rate for Payer: Humana Commercial |
$672.35
|
| Rate for Payer: Humana KY Medicaid |
$272.02
|
| Rate for Payer: Humana Medicare Advantage |
$207.09
|
| Rate for Payer: Kentucky WC Medicaid |
$274.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$648.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$248.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$696.08
|
| Rate for Payer: Ohio Health Group HMO |
$593.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$688.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.79
|
| Rate for Payer: PHCS Commercial |
$759.36
|
| Rate for Payer: United Healthcare All Payer |
$696.08
|
|
|
IABP BALLOON CATH 7.5 34CC
|
Facility
|
OP
|
$4,892.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,467.83 |
| Max. Negotiated Rate |
$4,697.04 |
| Rate for Payer: Aetna Commercial |
$3,767.42
|
| Rate for Payer: Anthem Medicaid |
$1,682.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,816.34
|
| Rate for Payer: Cash Price |
$2,446.38
|
| Rate for Payer: Cigna Commercial |
$4,060.98
|
| Rate for Payer: First Health Commercial |
$4,648.11
|
| Rate for Payer: Humana Commercial |
$4,158.84
|
| Rate for Payer: Humana KY Medicaid |
$1,682.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,699.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,012.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,610.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,467.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,716.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,305.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,669.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,914.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,256.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.00
|
| Rate for Payer: PHCS Commercial |
$4,697.04
|
| Rate for Payer: United Healthcare All Payer |
$4,305.62
|
|
|
IABP BALLOON CATH 7.5 34CC
|
Facility
|
IP
|
$4,892.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,467.83 |
| Max. Negotiated Rate |
$4,697.04 |
| Rate for Payer: Aetna Commercial |
$3,767.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,816.34
|
| Rate for Payer: Cash Price |
$2,446.38
|
| Rate for Payer: Cigna Commercial |
$4,060.98
|
| Rate for Payer: First Health Commercial |
$4,648.11
|
| Rate for Payer: Humana Commercial |
$4,158.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,012.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,610.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,467.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,305.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,669.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,914.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,256.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,376.00
|
| Rate for Payer: PHCS Commercial |
$4,697.04
|
| Rate for Payer: United Healthcare All Payer |
$4,305.62
|
|
