|
LASER SURG PENIS LESION(S)(P
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 54057
|
| Hospital Charge Code |
761P2126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.97 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Aetna Commercial |
$145.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.97
|
| Rate for Payer: Anthem Medicaid |
$80.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.00
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$124.76
|
| Rate for Payer: Healthspan PPO |
$206.20
|
| Rate for Payer: Humana Medicaid |
$80.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$125.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.41
|
| Rate for Payer: Molina Healthcare Passport |
$80.79
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.50
|
| Rate for Payer: UHCCP Medicaid |
$51.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.60
|
|
|
LASER SURG PENIS LESION(S)(T
|
Facility
|
IP
|
$4,571.00
|
|
|
Service Code
|
HCPCS 54057
|
| Hospital Charge Code |
761T2126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$594.23 |
| Max. Negotiated Rate |
$4,388.16 |
| Rate for Payer: Aetna Commercial |
$3,519.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,565.38
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cigna Commercial |
$3,793.93
|
| Rate for Payer: First Health Commercial |
$4,342.45
|
| Rate for Payer: Humana Commercial |
$3,885.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,748.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,373.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,022.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$914.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$594.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,417.01
|
| Rate for Payer: PHCS Commercial |
$4,388.16
|
| Rate for Payer: United Healthcare All Payer |
$4,022.48
|
|
|
LASER SURG PENIS LESION(S)(T
|
Facility
|
OP
|
$4,571.00
|
|
|
Service Code
|
HCPCS 54057
|
| Hospital Charge Code |
761T2126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$594.23 |
| Max. Negotiated Rate |
$4,388.16 |
| Rate for Payer: Aetna Commercial |
$3,519.67
|
| Rate for Payer: Anthem Medicaid |
$1,571.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,565.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cash Price |
$2,285.50
|
| Rate for Payer: Cigna Commercial |
$3,793.93
|
| Rate for Payer: First Health Commercial |
$4,342.45
|
| Rate for Payer: Humana Commercial |
$3,885.35
|
| Rate for Payer: Humana KY Medicaid |
$1,571.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,587.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,748.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,373.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,603.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,022.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$914.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$594.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,417.01
|
| Rate for Payer: PHCS Commercial |
$4,388.16
|
| Rate for Payer: United Healthcare All Payer |
$4,022.48
|
|
|
LASER VAP CERVIX
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.52 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$198.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.52
|
| Rate for Payer: Anthem Medicaid |
$133.87
|
| 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 |
$195.69
|
| Rate for Payer: Healthspan PPO |
$207.13
|
| Rate for Payer: Humana Medicaid |
$133.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$170.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.55
|
| Rate for Payer: Molina Healthcare Passport |
$133.87
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$109.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.21
|
|
|
LASER VAP CERVIX
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$3,784.94 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| 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 |
$2,703.53
|
| 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 |
$3,244.24
|
| 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
|
|
|
LASER VAP CERVIX
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
76102202
|
|
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
|
|
|
LASER VAP CERVIX(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 57513
|
| Hospital Charge Code |
761P2202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.52 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$198.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$104.52
|
| Rate for Payer: Anthem Medicaid |
$133.87
|
| 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 |
$195.69
|
| Rate for Payer: Healthspan PPO |
$207.13
|
| Rate for Payer: Humana Medicaid |
$133.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$170.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.55
|
| Rate for Payer: Molina Healthcare Passport |
$133.87
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$109.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.21
|
|
|
LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)
|
Facility
|
OP
|
$6,264.36
|
|
|
Service Code
|
CPT 52648
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,474.54 |
| Max. Negotiated Rate |
$6,264.36 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,264.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,040.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
|
|
LASIX 20 MG (40MG/5ML SOL)
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 54329863
|
| Hospital Charge Code |
25000844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
LASIX 20 MG (40MG/5ML SOL)
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 54329863
|
| Hospital Charge Code |
25000844
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
LASIX 20 MG IV (40MG/4ML VL)
|
Facility
|
OP
|
$75.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
636T0038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$72.86 |
| Rate for Payer: Aetna Commercial |
$58.44
|
| Rate for Payer: Anthem Medicaid |
$26.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Cigna Commercial |
$63.00
|
| Rate for Payer: First Health Commercial |
$72.10
|
| Rate for Payer: Humana Commercial |
$64.52
|
| Rate for Payer: Humana KY Medicaid |
$26.10
|
| Rate for Payer: Kentucky WC Medicaid |
$26.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.79
|
| Rate for Payer: Ohio Health Group HMO |
$56.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.53
|
| Rate for Payer: PHCS Commercial |
$72.86
|
| Rate for Payer: United Healthcare All Payer |
$66.79
|
|
|
LASIX 20 MG IV (40MG/4ML VL)
|
Professional
|
Both
|
$75.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
63600038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$75.90 |
| Rate for Payer: Aetna Commercial |
$0.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.90
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Healthspan PPO |
$0.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.09
|
| Rate for Payer: Multiplan PHCS |
$45.54
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.13
|
| Rate for Payer: UHCCP Medicaid |
$26.56
|
|
|
LASIX 20 MG IV (40MG/4ML VL)
|
Facility
|
IP
|
$75.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
63600038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$72.86 |
| Rate for Payer: Aetna Commercial |
$58.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Cigna Commercial |
$63.00
|
| Rate for Payer: First Health Commercial |
$72.10
|
| Rate for Payer: Humana Commercial |
$64.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.79
|
| Rate for Payer: Ohio Health Group HMO |
$56.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.53
|
| Rate for Payer: PHCS Commercial |
$72.86
|
| Rate for Payer: United Healthcare All Payer |
$66.79
|
|
|
LASIX 20 MG IV (40MG/4ML VL)
|
Facility
|
IP
|
$75.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
636T0038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$72.86 |
| Rate for Payer: Aetna Commercial |
$58.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Cigna Commercial |
$63.00
|
| Rate for Payer: First Health Commercial |
$72.10
|
| Rate for Payer: Humana Commercial |
$64.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.79
|
| Rate for Payer: Ohio Health Group HMO |
$56.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.53
|
| Rate for Payer: PHCS Commercial |
$72.86
|
| Rate for Payer: United Healthcare All Payer |
$66.79
|
|
|
LASIX 20 MG IV (40MG/4ML VL)
|
Facility
|
OP
|
$75.90
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
63600038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$72.86 |
| Rate for Payer: Aetna Commercial |
$58.44
|
| Rate for Payer: Anthem Medicaid |
$26.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.20
|
| Rate for Payer: Cash Price |
$37.95
|
| Rate for Payer: Cigna Commercial |
$63.00
|
| Rate for Payer: First Health Commercial |
$72.10
|
| Rate for Payer: Humana Commercial |
$64.52
|
| Rate for Payer: Humana KY Medicaid |
$26.10
|
| Rate for Payer: Kentucky WC Medicaid |
$26.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.79
|
| Rate for Payer: Ohio Health Group HMO |
$56.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.53
|
| Rate for Payer: PHCS Commercial |
$72.86
|
| Rate for Payer: United Healthcare All Payer |
$66.79
|
|
|
LASIX (FUROSEMIDE) 2 20MG/1TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 904717761
|
| Hospital Charge Code |
25000841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
LASIX (FUROSEMIDE) 2 20MG/1TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 904717761
|
| Hospital Charge Code |
25000841
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
LASIX (FUROSEMIDE) 4 40MG/1TAB
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 904717861
|
| Hospital Charge Code |
25000842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
LASIX (FUROSEMIDE) 4 40MG/1TAB
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 904717861
|
| Hospital Charge Code |
25000842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.11 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.55
|
| Rate for Payer: First Health Commercial |
$4.07
|
| Rate for Payer: Humana Commercial |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.77
|
| Rate for Payer: Ohio Health Group HMO |
$3.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.11
|
| Rate for Payer: United Healthcare All Payer |
$3.77
|
|
|
LASIX (FUROSEMIDE) 8 80MG/1TAB
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 51079052720
|
| Hospital Charge Code |
25000843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
LASIX (FUROSEMIDE) 8 80MG/1TAB
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 51079052720
|
| Hospital Charge Code |
25000843
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
OP
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$659.88 |
| Max. Negotiated Rate |
$4,872.96 |
| Rate for Payer: Aetna Commercial |
$3,908.52
|
| Rate for Payer: Anthem Medicaid |
$1,745.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$4,213.08
|
| Rate for Payer: First Health Commercial |
$4,822.20
|
| Rate for Payer: Humana Commercial |
$4,314.60
|
| Rate for Payer: Humana KY Medicaid |
$1,745.64
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,763.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,780.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,466.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,015.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,573.56
|
| Rate for Payer: PHCS Commercial |
$4,872.96
|
| Rate for Payer: United Healthcare All Payer |
$4,466.88
|
|
|
LATERAL CANTHOPEXY
|
Professional
|
Both
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.09 |
| Max. Negotiated Rate |
$5,076.00 |
| Rate for Payer: Aetna Commercial |
$487.53
|
| Rate for Payer: Anthem Medicaid |
$236.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,076.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$540.36
|
| Rate for Payer: Healthspan PPO |
$441.60
|
| Rate for Payer: Humana Medicaid |
$236.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.81
|
| Rate for Payer: Molina Healthcare Passport |
$236.09
|
| Rate for Payer: Multiplan PHCS |
$3,045.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,553.20
|
| Rate for Payer: UHCCP Medicaid |
$1,776.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.45
|
|
|
LATERAL CANTHOPEXY
|
Facility
|
IP
|
$5,076.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
76100377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$659.88 |
| Max. Negotiated Rate |
$4,872.96 |
| Rate for Payer: Aetna Commercial |
$3,908.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,959.28
|
| Rate for Payer: Cash Price |
$2,538.00
|
| Rate for Payer: Cigna Commercial |
$4,213.08
|
| Rate for Payer: First Health Commercial |
$4,822.20
|
| Rate for Payer: Humana Commercial |
$4,314.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,162.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,746.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,522.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,466.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,807.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,015.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$659.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,573.56
|
| Rate for Payer: PHCS Commercial |
$4,872.96
|
| Rate for Payer: United Healthcare All Payer |
$4,466.88
|
|
|
LATERAL CANTHOPEXY(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761P0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$487.53
|
| Rate for Payer: Anthem Medicaid |
$236.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$540.36
|
| Rate for Payer: Healthspan PPO |
$441.60
|
| Rate for Payer: Humana Medicaid |
$236.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.81
|
| Rate for Payer: Molina Healthcare Passport |
$236.09
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.45
|
|
