|
INSRT XLPE POLCP NON-CEM 67/28
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSTA-CHAR AQUEOUS 25GM/120ML
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
NDC 574052174
|
| Hospital Charge Code |
25000784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.95
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR AQUEOUS 25GM/120ML
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
NDC 574052174
|
| Hospital Charge Code |
25000784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem Medicaid |
$10.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Humana KY Medicaid |
$10.44
|
| Rate for Payer: Kentucky WC Medicaid |
$10.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.95
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR SORBITOL 25GM/120ML
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
NDC 574052074
|
| Hospital Charge Code |
25000785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.95
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR SORBITOL 25GM/120ML
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
NDC 574052074
|
| Hospital Charge Code |
25000785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem Medicaid |
$10.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Humana KY Medicaid |
$10.44
|
| Rate for Payer: Kentucky WC Medicaid |
$10.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.95
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-GLUCOSE TUBE 31 GM 31GM
|
Facility
|
IP
|
$11.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.70
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.26
|
| Rate for Payer: First Health Commercial |
$10.60
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.82
|
| Rate for Payer: Ohio Health Group HMO |
$8.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.70
|
| Rate for Payer: PHCS Commercial |
$10.71
|
| Rate for Payer: United Healthcare All Payer |
$9.82
|
|
|
INSTA-GLUCOSE TUBE 31 GM 31GM
|
Facility
|
OP
|
$11.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Anthem Medicaid |
$3.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.70
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.26
|
| Rate for Payer: First Health Commercial |
$10.60
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Humana KY Medicaid |
$3.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.82
|
| Rate for Payer: Ohio Health Group HMO |
$8.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.70
|
| Rate for Payer: PHCS Commercial |
$10.71
|
| Rate for Payer: United Healthcare All Payer |
$9.82
|
|
|
INSTANT PORE REFINER 29 G GBL
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
22200145
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
INSTANT PORE REFINER 29 G GBL
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
22200145
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
INSTANT PORE REFINER 29 G GBL
|
Professional
|
Both
|
$60.00
|
|
| Hospital Charge Code |
22200145
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$597.17 |
| Max. Negotiated Rate |
$1,556.12 |
| Rate for Payer: Aetna Commercial |
$1,556.12
|
| Rate for Payer: Ambetter Exchange |
$1,018.81
|
| Rate for Payer: Anthem Medicaid |
$597.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,018.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,018.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,222.57
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,444.55
|
| Rate for Payer: Healthspan PPO |
$1,312.31
|
| Rate for Payer: Humana Medicaid |
$597.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,376.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,018.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,018.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.11
|
| Rate for Payer: Molina Healthcare Passport |
$597.17
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,324.45
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,018.81
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$675.00 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem Medicaid |
$773.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Humana KY Medicaid |
$773.77
|
| Rate for Payer: Kentucky WC Medicaid |
$781.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$789.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,957.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,552.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$675.00 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,957.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,552.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
INSTESTINAL STRICTUROPLASTY(P
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
761P1858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$597.17 |
| Max. Negotiated Rate |
$1,556.12 |
| Rate for Payer: Aetna Commercial |
$1,556.12
|
| Rate for Payer: Ambetter Exchange |
$1,018.81
|
| Rate for Payer: Anthem Medicaid |
$597.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,018.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,018.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,222.57
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,444.55
|
| Rate for Payer: Healthspan PPO |
$1,312.31
|
| Rate for Payer: Humana Medicaid |
$597.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,376.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,018.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,018.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.11
|
| Rate for Payer: Molina Healthcare Passport |
$597.17
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,324.45
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,018.81
|
|
|
INST LEADLSS PACER SING CHAM
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.24 |
| Max. Negotiated Rate |
$24,669.92 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,621.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24,669.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$23,788.85
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$17,621.37
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,145.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INST LEADLSS PACER SING CHAM
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$1,120.00 |
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
|
|
INST LEADLSS PACER SING CHAM
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INSULIN LEVEL TOTAL
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS 83525
|
| Hospital Charge Code |
30000430
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.57
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
INSULIN LEVEL TOTAL
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 83525
|
| Hospital Charge Code |
30000430
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$119.04 |
| Rate for Payer: Aetna Commercial |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$11.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cash Price |
$62.00
|
| Rate for Payer: Cigna Commercial |
$102.92
|
| Rate for Payer: First Health Commercial |
$117.80
|
| Rate for Payer: Humana Commercial |
$105.40
|
| Rate for Payer: Humana KY Medicaid |
$11.43
|
| Rate for Payer: Humana Medicare Advantage |
$11.43
|
| Rate for Payer: Kentucky WC Medicaid |
$11.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$101.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$91.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$109.12
|
| Rate for Payer: Ohio Health Group HMO |
$93.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.56
|
| Rate for Payer: PHCS Commercial |
$119.04
|
| Rate for Payer: United Healthcare All Payer |
$109.12
|
|
|
INSULIN-TPN INJECTION IV(EA 5U
|
Facility
|
IP
|
$63.24
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$60.71 |
| Rate for Payer: Aetna Commercial |
$48.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.33
|
| Rate for Payer: Cash Price |
$31.62
|
| Rate for Payer: Cigna Commercial |
$52.49
|
| Rate for Payer: First Health Commercial |
$60.08
|
| Rate for Payer: Humana Commercial |
$53.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.65
|
| Rate for Payer: Ohio Health Group HMO |
$47.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.64
|
| Rate for Payer: PHCS Commercial |
$60.71
|
| Rate for Payer: United Healthcare All Payer |
$55.65
|
|
|
INSULIN-TPN INJECTION IV(EA 5U
|
Facility
|
OP
|
$63.24
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$60.71 |
| Rate for Payer: Aetna Commercial |
$48.69
|
| Rate for Payer: Anthem Medicaid |
$21.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.33
|
| Rate for Payer: Cash Price |
$31.62
|
| Rate for Payer: Cigna Commercial |
$52.49
|
| Rate for Payer: First Health Commercial |
$60.08
|
| Rate for Payer: Humana Commercial |
$53.75
|
| Rate for Payer: Humana KY Medicaid |
$21.75
|
| Rate for Payer: Kentucky WC Medicaid |
$21.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.65
|
| Rate for Payer: Ohio Health Group HMO |
$47.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.64
|
| Rate for Payer: PHCS Commercial |
$60.71
|
| Rate for Payer: United Healthcare All Payer |
$55.65
|
|
|
INS VAG BRACHYTX DEVICE
|
Facility
|
IP
|
$3,517.00
|
|
|
Service Code
|
HCPCS 57156
|
| Hospital Charge Code |
76102176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,055.10 |
| Max. Negotiated Rate |
$3,376.32 |
| Rate for Payer: Aetna Commercial |
$2,708.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,743.26
|
| Rate for Payer: Cash Price |
$1,758.50
|
| Rate for Payer: Cigna Commercial |
$2,919.11
|
| Rate for Payer: First Health Commercial |
$3,341.15
|
| Rate for Payer: Humana Commercial |
$2,989.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,883.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,595.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,094.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,637.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,059.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,426.73
|
| Rate for Payer: PHCS Commercial |
$3,376.32
|
| Rate for Payer: United Healthcare All Payer |
$3,094.96
|
|
|
INS VAG BRACHYTX DEVICE
|
Professional
|
Both
|
$3,517.00
|
|
|
Service Code
|
HCPCS 57156
|
| Hospital Charge Code |
76102176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.14 |
| Max. Negotiated Rate |
$2,110.20 |
| Rate for Payer: Aetna Commercial |
$164.16
|
| Rate for Payer: Ambetter Exchange |
$143.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.14
|
| Rate for Payer: Anthem Medicaid |
$130.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$143.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$143.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$172.60
|
| Rate for Payer: Cash Price |
$1,758.50
|
| Rate for Payer: Cash Price |
$1,758.50
|
| Rate for Payer: Cigna Commercial |
$257.25
|
| Rate for Payer: Healthspan PPO |
$173.09
|
| Rate for Payer: Humana Medicaid |
$130.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$143.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.46
|
| Rate for Payer: Molina Healthcare Passport |
$130.84
|
| Rate for Payer: Multiplan PHCS |
$2,110.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.98
|
| Rate for Payer: UHCCP Medicaid |
$79.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.83
|
|
|
INS VAG BRACHYTX DEVICE
|
Facility
|
OP
|
$3,517.00
|
|
|
Service Code
|
HCPCS 57156
|
| Hospital Charge Code |
76102176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$281.07 |
| Max. Negotiated Rate |
$3,376.32 |
| Rate for Payer: Aetna Commercial |
$2,708.09
|
| Rate for Payer: Anthem Medicaid |
$1,209.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$281.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,743.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$393.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$379.44
|
| Rate for Payer: Cash Price |
$1,758.50
|
| Rate for Payer: Cash Price |
$1,758.50
|
| Rate for Payer: Cigna Commercial |
$2,919.11
|
| Rate for Payer: First Health Commercial |
$3,341.15
|
| Rate for Payer: Humana Commercial |
$2,989.45
|
| Rate for Payer: Humana KY Medicaid |
$1,209.50
|
| Rate for Payer: Humana Medicare Advantage |
$281.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,221.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,883.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,595.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,233.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,094.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,637.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,059.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,426.73
|
| Rate for Payer: PHCS Commercial |
$3,376.32
|
| Rate for Payer: United Healthcare All Payer |
$3,094.96
|
|
|
INS VAG BRACHYTX DEVICE(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 57156
|
| Hospital Charge Code |
761P2176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.14 |
| Max. Negotiated Rate |
$257.25 |
| Rate for Payer: Aetna Commercial |
$164.16
|
| Rate for Payer: Ambetter Exchange |
$143.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.14
|
| Rate for Payer: Anthem Medicaid |
$130.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$143.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$143.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$172.60
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$257.25
|
| Rate for Payer: Healthspan PPO |
$173.09
|
| Rate for Payer: Humana Medicaid |
$130.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$143.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.46
|
| Rate for Payer: Molina Healthcare Passport |
$130.84
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.98
|
| Rate for Payer: UHCCP Medicaid |
$79.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.83
|
|
