|
MEDIASTINOTOMY W/EXPLORATION
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 39010
|
| Hospital Charge Code |
76101616
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.00 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
MEDIASTINOTOMY W/EXPLORATION
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 39010
|
| Hospital Charge Code |
76101616
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.00 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem Medicaid |
$636.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Humana KY Medicaid |
$636.22
|
| Rate for Payer: Kentucky WC Medicaid |
$642.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
MEDIASTINOTOMY W/EXPLORATION
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 39010
|
| Hospital Charge Code |
76101616
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$647.50 |
| Max. Negotiated Rate |
$1,295.99 |
| Rate for Payer: Aetna Commercial |
$1,237.50
|
| Rate for Payer: Ambetter Exchange |
$745.80
|
| Rate for Payer: Anthem Medicaid |
$674.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$745.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$894.96
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,295.99
|
| Rate for Payer: Healthspan PPO |
$989.49
|
| Rate for Payer: Humana Medicaid |
$674.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,066.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$745.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$745.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$687.72
|
| Rate for Payer: Molina Healthcare Passport |
$674.24
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$969.54
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$680.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$745.80
|
|
|
MEDIASTINOTOMY W/EXPLORATION(P
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 39010
|
| Hospital Charge Code |
761P1616
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$647.50 |
| Max. Negotiated Rate |
$1,295.99 |
| Rate for Payer: Aetna Commercial |
$1,237.50
|
| Rate for Payer: Ambetter Exchange |
$745.80
|
| Rate for Payer: Anthem Medicaid |
$674.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$745.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$894.96
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,295.99
|
| Rate for Payer: Healthspan PPO |
$989.49
|
| Rate for Payer: Humana Medicaid |
$674.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,066.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$745.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$745.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$687.72
|
| Rate for Payer: Molina Healthcare Passport |
$674.24
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$969.54
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$680.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$745.80
|
|
|
MEDICAL TESTIMONY/LEE
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 99075
|
| Hospital Charge Code |
51000057
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$63.54
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
MEDICAL TESTIMONY/LEE(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 99075
|
| Hospital Charge Code |
510P0057
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$63.54
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
MED NEB TX PENTAMIDINE
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS 94642
|
| Hospital Charge Code |
46000009
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.20
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
MED NEB TX PENTAMIDINE
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
HCPCS 94642
|
| Hospital Charge Code |
46000009
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$96.29 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem Medicaid |
$96.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$187.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$263.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$253.71
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Humana KY Medicaid |
$96.29
|
| Rate for Payer: Humana Medicare Advantage |
$187.93
|
| Rate for Payer: Kentucky WC Medicaid |
$97.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.20
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
MEDROL(METHYLPREDNISO 4MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
HCPCS J7509
|
| Hospital Charge Code |
25002496
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
MEDROL(METHYLPREDNISO 4MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
HCPCS J7509
|
| Hospital Charge Code |
25002496
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
MED SERV EVE/WKEND/HOLIDAY
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
51000056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem Medicaid |
$29.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Humana KY Medicaid |
$29.92
|
| Rate for Payer: Kentucky WC Medicaid |
$30.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.03
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
MED SERV EVE/WKEND/HOLIDAY
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
51000056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$60.90 |
| Rate for Payer: Aetna Commercial |
$27.87
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.36
|
| Rate for Payer: Multiplan PHCS |
$52.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$60.90
|
| Rate for Payer: UHCCP Medicaid |
$30.45
|
|
|
MED SERV EVE/WKEND/HOLIDAY
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
51000056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$83.52 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.86
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$72.21
|
| Rate for Payer: First Health Commercial |
$82.65
|
| Rate for Payer: Humana Commercial |
$73.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.56
|
| Rate for Payer: Ohio Health Group HMO |
$65.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.03
|
| Rate for Payer: PHCS Commercial |
$83.52
|
| Rate for Payer: United Healthcare All Payer |
$76.56
|
|
|
MED SERV EVE/WKEND/HOLIDAY(P
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
510P0056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$28.36 |
| Rate for Payer: Aetna Commercial |
$27.87
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.36
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
MED SERV EVE/WKEND/HOLIDAY(T
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
510T0056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.46
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.33
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
MED SERV EVE/WKEND/HOLIDAY(T
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS 99051
|
| Hospital Charge Code |
510T0056
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem Medicaid |
$19.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.46
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Humana KY Medicaid |
$19.60
|
| Rate for Payer: Kentucky WC Medicaid |
$19.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.33
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
MEFOXIN 1GM/10ML SYRINGE
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25003923
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
MEFOXIN 1GM/10ML SYRINGE
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25003923
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
MEFOXIN (CEFOXITIN) 1G 1GM/5ML
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25001938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.90 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
MEFOXIN (CEFOXITIN) 1G 1GM/5ML
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25001938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.90 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem Medicaid |
$38.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Humana KY Medicaid |
$38.86
|
| Rate for Payer: Kentucky WC Medicaid |
$39.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.97
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
MEFOXIN (CEFOXITIN) 2GRAM SYR
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25001940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
MEFOXIN (CEFOXITIN) 2GRAM SYR
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
25001940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.10 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.73
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
MEGA 30CC IAB
|
Facility
|
IP
|
$5,413.06
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,623.92 |
| Max. Negotiated Rate |
$5,196.54 |
| Rate for Payer: Aetna Commercial |
$4,168.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,222.19
|
| Rate for Payer: Cash Price |
$2,706.53
|
| Rate for Payer: Cigna Commercial |
$4,492.84
|
| Rate for Payer: First Health Commercial |
$5,142.41
|
| Rate for Payer: Humana Commercial |
$4,601.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,438.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,994.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,763.49
|
| Rate for Payer: Ohio Health Group HMO |
$4,059.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,330.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,709.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,735.01
|
| Rate for Payer: PHCS Commercial |
$5,196.54
|
| Rate for Payer: United Healthcare All Payer |
$4,763.49
|
|
|
MEGA 30CC IAB
|
Facility
|
OP
|
$5,413.06
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,623.92 |
| Max. Negotiated Rate |
$5,196.54 |
| Rate for Payer: Aetna Commercial |
$4,168.06
|
| Rate for Payer: Anthem Medicaid |
$1,861.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,222.19
|
| Rate for Payer: Cash Price |
$2,706.53
|
| Rate for Payer: Cigna Commercial |
$4,492.84
|
| Rate for Payer: First Health Commercial |
$5,142.41
|
| Rate for Payer: Humana Commercial |
$4,601.10
|
| Rate for Payer: Humana KY Medicaid |
$1,861.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,880.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,438.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,994.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,898.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,763.49
|
| Rate for Payer: Ohio Health Group HMO |
$4,059.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,330.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,709.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,735.01
|
| Rate for Payer: PHCS Commercial |
$5,196.54
|
| Rate for Payer: United Healthcare All Payer |
$4,763.49
|
|
|
MEGACE (MEGESTROL) 4 40MG/1TAB
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 555060702
|
| Hospital Charge Code |
25000954
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.98
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna Commercial |
$3.17
|
| Rate for Payer: First Health Commercial |
$3.63
|
| Rate for Payer: Humana Commercial |
$3.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.36
|
| Rate for Payer: Ohio Health Group HMO |
$2.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.64
|
| Rate for Payer: PHCS Commercial |
$3.67
|
| Rate for Payer: United Healthcare All Payer |
$3.36
|
|
