|
INSJ PICC RS&I 5 YR+
|
Professional
|
Both
|
$3,504.00
|
|
|
Service Code
|
HCPCS 36573
|
| Hospital Charge Code |
76101480
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$3,504.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$69.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,504.00
|
| Rate for Payer: Cash Price |
$1,752.00
|
| Rate for Payer: Cash Price |
$1,752.00
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Humana Medicaid |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.09
|
| Rate for Payer: Molina Healthcare Passport |
$69.70
|
| Rate for Payer: Multiplan PHCS |
$2,102.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,452.80
|
| Rate for Payer: UHCCP Medicaid |
$72.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.40
|
|
|
INSJ PICC RS&I 5 YR+(P
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 36573
|
| Hospital Charge Code |
761P1480
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.30 |
| Max. Negotiated Rate |
$290.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$69.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$141.61
|
| Rate for Payer: Humana Medicaid |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.09
|
| Rate for Payer: Molina Healthcare Passport |
$69.70
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.00
|
| Rate for Payer: UHCCP Medicaid |
$72.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.40
|
|
|
INSJ PICC RS&I 5 YR+(T
|
Facility
|
IP
|
$3,214.00
|
|
|
Service Code
|
HCPCS 36573
|
| Hospital Charge Code |
761T1480
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.82 |
| Max. Negotiated Rate |
$3,085.44 |
| Rate for Payer: Aetna Commercial |
$2,474.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,506.92
|
| Rate for Payer: Cash Price |
$1,607.00
|
| Rate for Payer: Cigna Commercial |
$2,667.62
|
| Rate for Payer: First Health Commercial |
$3,053.30
|
| Rate for Payer: Humana Commercial |
$2,731.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,635.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,371.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,828.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,410.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$642.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$996.34
|
| Rate for Payer: PHCS Commercial |
$3,085.44
|
| Rate for Payer: United Healthcare All Payer |
$2,828.32
|
|
|
INSJ PICC RS&I 5 YR+(T
|
Facility
|
OP
|
$3,214.00
|
|
|
Service Code
|
HCPCS 36573
|
| Hospital Charge Code |
761T1480
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.82 |
| Max. Negotiated Rate |
$3,085.44 |
| Rate for Payer: Aetna Commercial |
$2,474.78
|
| Rate for Payer: Anthem Medicaid |
$1,105.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,506.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$1,607.00
|
| Rate for Payer: Cash Price |
$1,607.00
|
| Rate for Payer: Cigna Commercial |
$2,667.62
|
| Rate for Payer: First Health Commercial |
$3,053.30
|
| Rate for Payer: Humana Commercial |
$2,731.90
|
| Rate for Payer: Humana KY Medicaid |
$1,105.29
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,116.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,635.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,371.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,127.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,828.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,410.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$642.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$996.34
|
| Rate for Payer: PHCS Commercial |
$3,085.44
|
| Rate for Payer: United Healthcare All Payer |
$2,828.32
|
|
|
INSPACE BALLOON IMPLANT - LARG
|
Facility
|
IP
|
$28,525.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,708.25 |
| Max. Negotiated Rate |
$27,384.00 |
| Rate for Payer: Aetna Commercial |
$21,964.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,249.50
|
| Rate for Payer: Cash Price |
$14,262.50
|
| Rate for Payer: Cigna Commercial |
$23,675.75
|
| Rate for Payer: First Health Commercial |
$27,098.75
|
| Rate for Payer: Humana Commercial |
$24,246.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,390.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,051.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,557.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,102.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,393.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,705.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,708.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,842.75
|
| Rate for Payer: PHCS Commercial |
$27,384.00
|
| Rate for Payer: United Healthcare All Payer |
$25,102.00
|
|
|
INSPACE BALLOON IMPLANT - LARG
|
Facility
|
OP
|
$28,525.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,708.25 |
| Max. Negotiated Rate |
$27,384.00 |
| Rate for Payer: Aetna Commercial |
$21,964.25
|
| Rate for Payer: Anthem Medicaid |
$9,809.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,249.50
|
| Rate for Payer: Cash Price |
$14,262.50
|
| Rate for Payer: Cigna Commercial |
$23,675.75
|
| Rate for Payer: First Health Commercial |
$27,098.75
|
| Rate for Payer: Humana Commercial |
$24,246.25
|
| Rate for Payer: Humana KY Medicaid |
$9,809.75
|
| Rate for Payer: Kentucky WC Medicaid |
$9,909.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,390.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,051.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,557.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,102.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,393.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,705.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,708.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,842.75
|
| Rate for Payer: PHCS Commercial |
$27,384.00
|
| Rate for Payer: United Healthcare All Payer |
$25,102.00
|
|
|
INSPACE BALLOON IMPLANT - MEDI
|
Facility
|
OP
|
$30,331.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,943.13 |
| Max. Negotiated Rate |
$29,118.48 |
| Rate for Payer: Aetna Commercial |
$23,355.45
|
| Rate for Payer: Anthem Medicaid |
$10,431.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,658.76
|
| Rate for Payer: Cash Price |
$15,165.88
|
| Rate for Payer: Cigna Commercial |
$25,175.35
|
| Rate for Payer: First Health Commercial |
$28,815.16
|
| Rate for Payer: Humana Commercial |
$25,781.99
|
| Rate for Payer: Humana KY Medicaid |
$10,431.09
|
| Rate for Payer: Kentucky WC Medicaid |
$10,537.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,872.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,384.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,099.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,640.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,691.94
|
| Rate for Payer: Ohio Health Group HMO |
$22,748.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,066.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,943.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,402.84
|
| Rate for Payer: PHCS Commercial |
$29,118.48
|
| Rate for Payer: United Healthcare All Payer |
$26,691.94
|
|
|
INSPACE BALLOON IMPLANT - MEDI
|
Facility
|
IP
|
$30,331.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,943.13 |
| Max. Negotiated Rate |
$29,118.48 |
| Rate for Payer: Aetna Commercial |
$23,355.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,658.76
|
| Rate for Payer: Cash Price |
$15,165.88
|
| Rate for Payer: Cigna Commercial |
$25,175.35
|
| Rate for Payer: First Health Commercial |
$28,815.16
|
| Rate for Payer: Humana Commercial |
$25,781.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,872.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,384.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,099.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,691.94
|
| Rate for Payer: Ohio Health Group HMO |
$22,748.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,066.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,943.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,402.84
|
| Rate for Payer: PHCS Commercial |
$29,118.48
|
| Rate for Payer: United Healthcare All Payer |
$26,691.94
|
|
|
INS PICC <5 YR W/O IMAGING
|
Professional
|
Both
|
$2,563.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
76102652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.74 |
| Max. Negotiated Rate |
$2,563.00 |
| Rate for Payer: Aetna Commercial |
$152.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.74
|
| Rate for Payer: Anthem Medicaid |
$75.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,563.00
|
| Rate for Payer: Cash Price |
$1,281.50
|
| Rate for Payer: Cash Price |
$1,281.50
|
| Rate for Payer: Cigna Commercial |
$139.80
|
| Rate for Payer: Healthspan PPO |
$361.93
|
| Rate for Payer: Humana Medicaid |
$75.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.09
|
| Rate for Payer: Molina Healthcare Passport |
$75.58
|
| Rate for Payer: Multiplan PHCS |
$1,537.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,794.10
|
| Rate for Payer: UHCCP Medicaid |
$73.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.34
|
|
|
INS PICC <5 YR W/O IMAGING
|
Facility
|
IP
|
$2,563.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
76102652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$333.19 |
| Max. Negotiated Rate |
$2,460.48 |
| Rate for Payer: Aetna Commercial |
$1,973.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,999.14
|
| Rate for Payer: Cash Price |
$1,281.50
|
| Rate for Payer: Cigna Commercial |
$2,127.29
|
| Rate for Payer: First Health Commercial |
$2,434.85
|
| Rate for Payer: Humana Commercial |
$2,178.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,101.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,891.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$768.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,255.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,922.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$333.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$794.53
|
| Rate for Payer: PHCS Commercial |
$2,460.48
|
| Rate for Payer: United Healthcare All Payer |
$2,255.44
|
|
|
INS PICC <5 YR W/O IMAGING
|
Facility
|
OP
|
$2,563.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
76102652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$333.19 |
| Max. Negotiated Rate |
$2,460.48 |
| Rate for Payer: Aetna Commercial |
$1,973.51
|
| Rate for Payer: Anthem Medicaid |
$881.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,999.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$1,281.50
|
| Rate for Payer: Cash Price |
$1,281.50
|
| Rate for Payer: Cigna Commercial |
$2,127.29
|
| Rate for Payer: First Health Commercial |
$2,434.85
|
| Rate for Payer: Humana Commercial |
$2,178.55
|
| Rate for Payer: Humana KY Medicaid |
$881.42
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$890.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,101.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,891.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$899.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,255.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,922.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$333.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$794.53
|
| Rate for Payer: PHCS Commercial |
$2,460.48
|
| Rate for Payer: United Healthcare All Payer |
$2,255.44
|
|
|
INS PICC <5 YR W/O IMAGING (P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
761P2652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.74 |
| Max. Negotiated Rate |
$361.93 |
| Rate for Payer: Aetna Commercial |
$152.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.74
|
| Rate for Payer: Anthem Medicaid |
$75.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$139.80
|
| Rate for Payer: Healthspan PPO |
$361.93
|
| Rate for Payer: Humana Medicaid |
$75.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.09
|
| Rate for Payer: Molina Healthcare Passport |
$75.58
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$73.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.34
|
|
|
INS PICC <5 YR W/O IMAGING (T
|
Facility
|
OP
|
$2,263.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
761T2652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.19 |
| Max. Negotiated Rate |
$2,172.48 |
| Rate for Payer: Aetna Commercial |
$1,742.51
|
| Rate for Payer: Anthem Medicaid |
$778.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,765.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$1,131.50
|
| Rate for Payer: Cash Price |
$1,131.50
|
| Rate for Payer: Cigna Commercial |
$1,878.29
|
| Rate for Payer: First Health Commercial |
$2,149.85
|
| Rate for Payer: Humana Commercial |
$1,923.55
|
| Rate for Payer: Humana KY Medicaid |
$778.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$786.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,855.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,670.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$793.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,991.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,697.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.53
|
| Rate for Payer: PHCS Commercial |
$2,172.48
|
| Rate for Payer: United Healthcare All Payer |
$1,991.44
|
|
|
INS PICC <5 YR W/O IMAGING (T
|
Facility
|
IP
|
$2,263.00
|
|
|
Service Code
|
HCPCS 36568
|
| Hospital Charge Code |
761T2652
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.19 |
| Max. Negotiated Rate |
$2,172.48 |
| Rate for Payer: Aetna Commercial |
$1,742.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,765.14
|
| Rate for Payer: Cash Price |
$1,131.50
|
| Rate for Payer: Cigna Commercial |
$1,878.29
|
| Rate for Payer: First Health Commercial |
$2,149.85
|
| Rate for Payer: Humana Commercial |
$1,923.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,855.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,670.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,991.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,697.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$452.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.53
|
| Rate for Payer: PHCS Commercial |
$2,172.48
|
| Rate for Payer: United Healthcare All Payer |
$1,991.44
|
|
|
INSPRA EPLERENONE 25MG TAB
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
NDC 59762171002
|
| Hospital Charge Code |
25000782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.02 |
| Rate for Payer: Aetna Commercial |
$7.24
|
| Rate for Payer: Anthem Medicaid |
$3.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.33
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna Commercial |
$7.80
|
| Rate for Payer: First Health Commercial |
$8.93
|
| Rate for Payer: Humana Commercial |
$7.99
|
| Rate for Payer: Humana KY Medicaid |
$3.23
|
| Rate for Payer: Kentucky WC Medicaid |
$3.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.27
|
| Rate for Payer: Ohio Health Group HMO |
$7.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$9.02
|
| Rate for Payer: United Healthcare All Payer |
$8.27
|
|
|
INSPRA EPLERENONE 25MG TAB
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
NDC 59762171002
|
| Hospital Charge Code |
25000782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.02 |
| Rate for Payer: Aetna Commercial |
$7.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.33
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna Commercial |
$7.80
|
| Rate for Payer: First Health Commercial |
$8.93
|
| Rate for Payer: Humana Commercial |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.27
|
| Rate for Payer: Ohio Health Group HMO |
$7.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$9.02
|
| Rate for Payer: United Healthcare All Payer |
$8.27
|
|
|
INSPRA(EPLERENONE)50MG TAB
|
Facility
|
IP
|
$31.79
|
|
|
Service Code
|
NDC 58151014393
|
| Hospital Charge Code |
25000783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$30.52 |
| Rate for Payer: Aetna Commercial |
$24.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.80
|
| Rate for Payer: Cash Price |
$15.89
|
| Rate for Payer: Cigna Commercial |
$26.39
|
| Rate for Payer: First Health Commercial |
$30.20
|
| Rate for Payer: Humana Commercial |
$27.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.98
|
| Rate for Payer: Ohio Health Group HMO |
$23.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.85
|
| Rate for Payer: PHCS Commercial |
$30.52
|
| Rate for Payer: United Healthcare All Payer |
$27.98
|
|
|
INSPRA(EPLERENONE)50MG TAB
|
Facility
|
OP
|
$31.79
|
|
|
Service Code
|
NDC 58151014393
|
| Hospital Charge Code |
25000783
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.13 |
| Max. Negotiated Rate |
$30.52 |
| Rate for Payer: Aetna Commercial |
$24.48
|
| Rate for Payer: Anthem Medicaid |
$10.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.80
|
| Rate for Payer: Cash Price |
$15.89
|
| Rate for Payer: Cigna Commercial |
$26.39
|
| Rate for Payer: First Health Commercial |
$30.20
|
| Rate for Payer: Humana Commercial |
$27.02
|
| Rate for Payer: Humana KY Medicaid |
$10.93
|
| Rate for Payer: Kentucky WC Medicaid |
$11.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.98
|
| Rate for Payer: Ohio Health Group HMO |
$23.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.85
|
| Rate for Payer: PHCS Commercial |
$30.52
|
| Rate for Payer: United Healthcare All Payer |
$27.98
|
|
|
INS/REP SUBQ DEFIBRILLATOR
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 33270
|
| Hospital Charge Code |
76101277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
INS/REP SUBQ DEFIBRILLATOR
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 33270
|
| Hospital Charge Code |
76101277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$1,071.27 |
| Rate for Payer: Anthem Medicaid |
$471.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$1,071.27
|
| Rate for Payer: Humana Medicaid |
$471.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$781.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$480.61
|
| Rate for Payer: Molina Healthcare Passport |
$471.19
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$475.90
|
|
|
INS/REP SUBQ DEFIBRILLATOR
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 33270
|
| Hospital Charge Code |
76101277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$39,829.45 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28,449.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39,829.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$38,406.97
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$28,449.61
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34,139.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
INS/REP SUBQ DEFIBRILLATOR(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 33270
|
| Hospital Charge Code |
761P1277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$1,071.27 |
| Rate for Payer: Anthem Medicaid |
$471.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$1,071.27
|
| Rate for Payer: Humana Medicaid |
$471.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$781.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$480.61
|
| Rate for Payer: Molina Healthcare Passport |
$471.19
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$475.90
|
|
|
INSRT BLAD TMP INDWLCATH CMPLX
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 51703
|
| Hospital Charge Code |
48100042
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$42.51 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem Medicaid |
$112.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Humana KY Medicaid |
$112.46
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$113.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.37
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
|
INSRT BLAD TMP INDWLCATH CMPLX
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 51703
|
| Hospital Charge Code |
761T2067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.51 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem Medicaid |
$112.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Humana KY Medicaid |
$112.46
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$113.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.37
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
|
INSRT BLAD TMP INDWLCATH CMPLX
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 51703
|
| Hospital Charge Code |
761T2067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.51 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.37
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
