|
JAGWIR GUIDWIR .035*260 ANGLE
|
Facility
|
IP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
|
JANUVIA SITAGLIPTIN 100MG TAB
|
Facility
|
OP
|
$36.10
|
|
|
Service Code
|
NDC 6027782
|
| Hospital Charge Code |
25000804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Humana Commercial |
$30.68
|
| Rate for Payer: Humana KY Medicaid |
$12.41
|
| Rate for Payer: Kentucky WC Medicaid |
$12.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.77
|
| Rate for Payer: Ohio Health Group HMO |
$27.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.19
|
| Rate for Payer: PHCS Commercial |
$34.66
|
| Rate for Payer: United Healthcare All Payer |
$31.77
|
| Rate for Payer: Aetna Commercial |
$27.80
|
| Rate for Payer: Anthem Medicaid |
$12.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.16
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cigna Commercial |
$29.96
|
| Rate for Payer: First Health Commercial |
$34.30
|
|
|
JANUVIA SITAGLIPTIN 100MG TAB
|
Facility
|
IP
|
$36.10
|
|
|
Service Code
|
NDC 6027782
|
| Hospital Charge Code |
25000804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$27.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.16
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cigna Commercial |
$29.96
|
| Rate for Payer: First Health Commercial |
$34.30
|
| Rate for Payer: Humana Commercial |
$30.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.77
|
| Rate for Payer: Ohio Health Group HMO |
$27.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.19
|
| Rate for Payer: PHCS Commercial |
$34.66
|
| Rate for Payer: United Healthcare All Payer |
$31.77
|
|
|
JANUVIA SITAGLIPTIN 50MG TAB
|
Facility
|
IP
|
$36.10
|
|
|
Service Code
|
NDC 6011231
|
| Hospital Charge Code |
25000806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$27.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.16
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cigna Commercial |
$29.96
|
| Rate for Payer: First Health Commercial |
$34.30
|
| Rate for Payer: Humana Commercial |
$30.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.77
|
| Rate for Payer: Ohio Health Group HMO |
$27.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.19
|
| Rate for Payer: PHCS Commercial |
$34.66
|
| Rate for Payer: United Healthcare All Payer |
$31.77
|
|
|
JANUVIA SITAGLIPTIN 50MG TAB
|
Facility
|
OP
|
$36.10
|
|
|
Service Code
|
NDC 6011231
|
| Hospital Charge Code |
25000806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$27.80
|
| Rate for Payer: Anthem Medicaid |
$12.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.16
|
| Rate for Payer: Cash Price |
$18.05
|
| Rate for Payer: Cigna Commercial |
$29.96
|
| Rate for Payer: First Health Commercial |
$34.30
|
| Rate for Payer: Humana Commercial |
$30.68
|
| Rate for Payer: Humana KY Medicaid |
$12.41
|
| Rate for Payer: Kentucky WC Medicaid |
$12.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.77
|
| Rate for Payer: Ohio Health Group HMO |
$27.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.19
|
| Rate for Payer: PHCS Commercial |
$34.66
|
| Rate for Payer: United Healthcare All Payer |
$31.77
|
|
|
JARDIANCE 10MG TABLET
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
NDC 597015230
|
| Hospital Charge Code |
25000807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$35.88 |
| Rate for Payer: Aetna Commercial |
$28.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.15
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$31.02
|
| Rate for Payer: First Health Commercial |
$35.50
|
| Rate for Payer: Humana Commercial |
$31.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.89
|
| Rate for Payer: Ohio Health Group HMO |
$28.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.58
|
| Rate for Payer: PHCS Commercial |
$35.88
|
| Rate for Payer: United Healthcare All Payer |
$32.89
|
|
|
JARDIANCE 10MG TABLET
|
Facility
|
OP
|
$37.37
|
|
|
Service Code
|
NDC 597015230
|
| Hospital Charge Code |
25000807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$35.88 |
| Rate for Payer: Aetna Commercial |
$28.77
|
| Rate for Payer: Anthem Medicaid |
$12.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.15
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$31.02
|
| Rate for Payer: First Health Commercial |
$35.50
|
| Rate for Payer: Humana Commercial |
$31.76
|
| Rate for Payer: Humana KY Medicaid |
$12.85
|
| Rate for Payer: Kentucky WC Medicaid |
$12.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.89
|
| Rate for Payer: Ohio Health Group HMO |
$28.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.58
|
| Rate for Payer: PHCS Commercial |
$35.88
|
| Rate for Payer: United Healthcare All Payer |
$32.89
|
|
|
JARDIANCE 25MG TABLET
|
Facility
|
OP
|
$37.37
|
|
|
Service Code
|
NDC 597015330
|
| Hospital Charge Code |
25000808
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$35.88 |
| Rate for Payer: Aetna Commercial |
$28.77
|
| Rate for Payer: Anthem Medicaid |
$12.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.15
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$31.02
|
| Rate for Payer: First Health Commercial |
$35.50
|
| Rate for Payer: Humana Commercial |
$31.76
|
| Rate for Payer: Humana KY Medicaid |
$12.85
|
| Rate for Payer: Kentucky WC Medicaid |
$12.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.89
|
| Rate for Payer: Ohio Health Group HMO |
$28.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.58
|
| Rate for Payer: PHCS Commercial |
$35.88
|
| Rate for Payer: United Healthcare All Payer |
$32.89
|
|
|
JARDIANCE 25MG TABLET
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
NDC 597015330
|
| Hospital Charge Code |
25000808
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$35.88 |
| Rate for Payer: Aetna Commercial |
$28.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.15
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cigna Commercial |
$31.02
|
| Rate for Payer: First Health Commercial |
$35.50
|
| Rate for Payer: Humana Commercial |
$31.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$32.89
|
| Rate for Payer: Ohio Health Group HMO |
$28.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11.58
|
| Rate for Payer: PHCS Commercial |
$35.88
|
| Rate for Payer: United Healthcare All Payer |
$32.89
|
|
|
JAW ARTHROSCOPY/SURGERY
|
Facility
|
IP
|
$725.00
|
|
|
Service Code
|
HCPCS 29800
|
| Hospital Charge Code |
76101073
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$696.00 |
| Rate for Payer: Aetna Commercial |
$558.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$565.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$601.75
|
| Rate for Payer: First Health Commercial |
$688.75
|
| Rate for Payer: Humana Commercial |
$616.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$594.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$535.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$638.00
|
| Rate for Payer: Ohio Health Group HMO |
$543.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.75
|
| Rate for Payer: PHCS Commercial |
$696.00
|
| Rate for Payer: United Healthcare All Payer |
$638.00
|
|
|
JAW ARTHROSCOPY/SURGERY
|
Professional
|
Both
|
$725.00
|
|
|
Service Code
|
HCPCS 29800
|
| Hospital Charge Code |
76101073
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$870.51 |
| Rate for Payer: Aetna Commercial |
$752.82
|
| Rate for Payer: Anthem Medicaid |
$273.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$725.00
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$870.51
|
| Rate for Payer: Healthspan PPO |
$681.89
|
| Rate for Payer: Humana Medicaid |
$273.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$648.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.14
|
| Rate for Payer: Molina Healthcare Passport |
$273.67
|
| Rate for Payer: Multiplan PHCS |
$435.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$507.50
|
| Rate for Payer: UHCCP Medicaid |
$253.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.41
|
|
|
JAW ARTHROSCOPY/SURGERY
|
Facility
|
OP
|
$725.00
|
|
|
Service Code
|
HCPCS 29800
|
| Hospital Charge Code |
76101073
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.25 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$558.25
|
| Rate for Payer: Anthem Medicaid |
$249.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$565.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$601.75
|
| Rate for Payer: First Health Commercial |
$688.75
|
| Rate for Payer: Humana Commercial |
$616.25
|
| Rate for Payer: Humana KY Medicaid |
$249.33
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$251.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$594.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$535.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$254.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$638.00
|
| Rate for Payer: Ohio Health Group HMO |
$543.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.75
|
| Rate for Payer: PHCS Commercial |
$696.00
|
| Rate for Payer: United Healthcare All Payer |
$638.00
|
|
|
JAW ARTHROSCOPY/SURGERY(P
|
Professional
|
Both
|
$725.00
|
|
|
Service Code
|
HCPCS 29800
|
| Hospital Charge Code |
761P1073
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$870.51 |
| Rate for Payer: Aetna Commercial |
$752.82
|
| Rate for Payer: Anthem Medicaid |
$273.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$725.00
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$870.51
|
| Rate for Payer: Healthspan PPO |
$681.89
|
| Rate for Payer: Humana Medicaid |
$273.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$648.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$279.14
|
| Rate for Payer: Molina Healthcare Passport |
$273.67
|
| Rate for Payer: Multiplan PHCS |
$435.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$507.50
|
| Rate for Payer: UHCCP Medicaid |
$253.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$276.41
|
|
|
JB2 CATH
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JB2 CATH
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JB2 SLIP CATH
|
Facility
|
OP
|
$1,574.62
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.70 |
| Max. Negotiated Rate |
$1,511.64 |
| Rate for Payer: Aetna Commercial |
$1,212.46
|
| Rate for Payer: Anthem Medicaid |
$541.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.20
|
| Rate for Payer: Cash Price |
$787.31
|
| Rate for Payer: Cigna Commercial |
$1,306.93
|
| Rate for Payer: First Health Commercial |
$1,495.89
|
| Rate for Payer: Humana Commercial |
$1,338.43
|
| Rate for Payer: Humana KY Medicaid |
$541.51
|
| Rate for Payer: Kentucky WC Medicaid |
$547.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$552.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,385.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,180.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.13
|
| Rate for Payer: PHCS Commercial |
$1,511.64
|
| Rate for Payer: United Healthcare All Payer |
$1,385.67
|
|
|
JB2 SLIP CATH
|
Facility
|
IP
|
$1,574.62
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.70 |
| Max. Negotiated Rate |
$1,511.64 |
| Rate for Payer: Aetna Commercial |
$1,212.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.20
|
| Rate for Payer: Cash Price |
$787.31
|
| Rate for Payer: Cigna Commercial |
$1,306.93
|
| Rate for Payer: First Health Commercial |
$1,495.89
|
| Rate for Payer: Humana Commercial |
$1,338.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,385.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,180.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.13
|
| Rate for Payer: PHCS Commercial |
$1,511.64
|
| Rate for Payer: United Healthcare All Payer |
$1,385.67
|
|
|
JEJUNOSTOMY TUBE
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 44015
|
| Hospital Charge Code |
76101804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
JEJUNOSTOMY TUBE
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 44015
|
| Hospital Charge Code |
76101804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
JEJUNOSTOMY TUBE
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 44015
|
| Hospital Charge Code |
76101804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$217.90
|
| Rate for Payer: Anthem Medicaid |
$174.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$204.93
|
| Rate for Payer: Healthspan PPO |
$183.76
|
| Rate for Payer: Humana Medicaid |
$174.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.66
|
| Rate for Payer: Molina Healthcare Passport |
$174.18
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.92
|
|
|
JEJUNOSTOMY TUBE(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 44015
|
| Hospital Charge Code |
761P1804
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$217.90
|
| Rate for Payer: Anthem Medicaid |
$174.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$204.93
|
| Rate for Payer: Healthspan PPO |
$183.76
|
| Rate for Payer: Humana Medicaid |
$174.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.66
|
| Rate for Payer: Molina Healthcare Passport |
$174.18
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.92
|
|
|
JEMPERLI 10mg (500mg SDV)
|
Facility
|
IP
|
$63,019.00
|
|
|
Service Code
|
HCPCS J9272
|
| Hospital Charge Code |
25004100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,192.47 |
| Max. Negotiated Rate |
$60,498.24 |
| Rate for Payer: Aetna Commercial |
$48,524.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49,154.82
|
| Rate for Payer: Cash Price |
$31,509.50
|
| Rate for Payer: Cigna Commercial |
$52,305.77
|
| Rate for Payer: First Health Commercial |
$59,868.05
|
| Rate for Payer: Humana Commercial |
$53,566.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,675.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,508.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,905.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,456.72
|
| Rate for Payer: Ohio Health Group HMO |
$47,264.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,603.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,192.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,535.89
|
| Rate for Payer: PHCS Commercial |
$60,498.24
|
| Rate for Payer: United Healthcare All Payer |
$55,456.72
|
|
|
JEMPERLI 10mg (500mg SDV)
|
Facility
|
OP
|
$63,019.00
|
|
|
Service Code
|
HCPCS J9272
|
| Hospital Charge Code |
25004100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.26 |
| Max. Negotiated Rate |
$60,498.24 |
| Rate for Payer: Aetna Commercial |
$48,524.63
|
| Rate for Payer: Anthem Medicaid |
$21,672.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$233.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49,154.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$326.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$314.90
|
| Rate for Payer: Cash Price |
$31,509.50
|
| Rate for Payer: Cash Price |
$31,509.50
|
| Rate for Payer: Cigna Commercial |
$52,305.77
|
| Rate for Payer: First Health Commercial |
$59,868.05
|
| Rate for Payer: Humana Commercial |
$53,566.15
|
| Rate for Payer: Humana KY Medicaid |
$21,672.23
|
| Rate for Payer: Humana Medicare Advantage |
$233.26
|
| Rate for Payer: Kentucky WC Medicaid |
$21,892.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51,675.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46,508.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,107.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$55,456.72
|
| Rate for Payer: Ohio Health Group HMO |
$47,264.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,603.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,192.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,535.89
|
| Rate for Payer: PHCS Commercial |
$60,498.24
|
| Rate for Payer: United Healthcare All Payer |
$55,456.72
|
|
|
JETSTREAM SC 1.65
|
Facility
|
OP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,085.72 |
| Max. Negotiated Rate |
$15,402.24 |
| Rate for Payer: Aetna Commercial |
$12,353.88
|
| Rate for Payer: Anthem Medicaid |
$5,517.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,514.32
|
| Rate for Payer: Cash Price |
$8,022.00
|
| Rate for Payer: Cigna Commercial |
$13,316.52
|
| Rate for Payer: First Health Commercial |
$15,241.80
|
| Rate for Payer: Humana Commercial |
$13,637.40
|
| Rate for Payer: Humana KY Medicaid |
$5,517.53
|
| Rate for Payer: Kentucky WC Medicaid |
$5,573.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,156.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,840.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,813.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,628.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,118.72
|
| Rate for Payer: Ohio Health Group HMO |
$12,033.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,085.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,973.64
|
| Rate for Payer: PHCS Commercial |
$15,402.24
|
| Rate for Payer: United Healthcare All Payer |
$14,118.72
|
|
|
JETSTREAM SC 1.65
|
Facility
|
IP
|
$16,044.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,085.72 |
| Max. Negotiated Rate |
$15,402.24 |
| Rate for Payer: Aetna Commercial |
$12,353.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,514.32
|
| Rate for Payer: Cash Price |
$8,022.00
|
| Rate for Payer: Cigna Commercial |
$13,316.52
|
| Rate for Payer: First Health Commercial |
$15,241.80
|
| Rate for Payer: Humana Commercial |
$13,637.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,156.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,840.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,813.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,118.72
|
| Rate for Payer: Ohio Health Group HMO |
$12,033.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,085.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,973.64
|
| Rate for Payer: PHCS Commercial |
$15,402.24
|
| Rate for Payer: United Healthcare All Payer |
$14,118.72
|
|
