|
MOBIC MELOXICAMO 7.5 MG CAP
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 68382005001
|
| Hospital Charge Code |
25001005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
MOBIC MELOXICAMO 7.5 MG CAP
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 68382005001
|
| Hospital Charge Code |
25001005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
MOBILE CHARGING SYSTEM 3711
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
MOBILE CHARGING SYSTEM 3711
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1820
|
| Hospital Charge Code |
27000082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
MOBILIZATION OF TESTICLE
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.20 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem Medicaid |
$220.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Humana KY Medicaid |
$220.10
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$222.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.40
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
MOBILIZATION OF TESTICLE
|
Professional
|
Both
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$640.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$384.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$448.00
|
| Rate for Payer: UHCCP Medicaid |
$224.00
|
|
|
MOBILIZATION OF TESTICLE
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
HCPCS 55899
|
| Hospital Charge Code |
76102950
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.20 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.40
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.76
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
761P1813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$182.93
|
| Rate for Payer: Anthem Medicaid |
$103.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$173.68
|
| Rate for Payer: Healthspan PPO |
$154.26
|
| Rate for Payer: Humana Medicaid |
$103.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.45
|
| Rate for Payer: Molina Healthcare Passport |
$103.38
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.41
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$182.93
|
| Rate for Payer: Anthem Medicaid |
$103.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$173.68
|
| Rate for Payer: Healthspan PPO |
$154.26
|
| Rate for Payer: Humana Medicaid |
$103.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$156.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.45
|
| Rate for Payer: Molina Healthcare Passport |
$103.38
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$157.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.41
|
|
|
MOBILIZATION (TAKE-DOWN) OF SP
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
76101813
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
MOBISYL 226.8 GM
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 225036035
|
| Hospital Charge Code |
25004138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
MOBISYL 226.8 GM
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 225036035
|
| Hospital Charge Code |
25004138
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Professional
|
Both
|
$563.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$563.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$10.11
|
| Rate for Payer: Anthem Medicaid |
$9.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$563.00
|
| Rate for Payer: Cash Price |
$281.50
|
| Rate for Payer: Cash Price |
$281.50
|
| Rate for Payer: Cigna Commercial |
$70.32
|
| Rate for Payer: Humana Medicaid |
$9.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$10.18
|
| Rate for Payer: Molina Healthcare Passport |
$9.98
|
| Rate for Payer: Multiplan PHCS |
$337.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$394.10
|
| Rate for Payer: UHCCP Medicaid |
$10.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.08
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Facility
|
OP
|
$563.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$73.19 |
| Max. Negotiated Rate |
$540.48 |
| Rate for Payer: Aetna Commercial |
$433.51
|
| Rate for Payer: Anthem Medicaid |
$193.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.14
|
| Rate for Payer: Cash Price |
$281.50
|
| Rate for Payer: Cigna Commercial |
$467.29
|
| Rate for Payer: First Health Commercial |
$534.85
|
| Rate for Payer: Humana Commercial |
$478.55
|
| Rate for Payer: Humana KY Medicaid |
$193.62
|
| Rate for Payer: Kentucky WC Medicaid |
$195.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$461.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$415.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$197.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$495.44
|
| Rate for Payer: Ohio Health Group HMO |
$422.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.53
|
| Rate for Payer: PHCS Commercial |
$540.48
|
| Rate for Payer: United Healthcare All Payer |
$495.44
|
|
|
MODERATE SEDATION 1ST 15 MIN
|
Facility
|
IP
|
$563.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
37000173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$73.19 |
| Max. Negotiated Rate |
$540.48 |
| Rate for Payer: Aetna Commercial |
$433.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.14
|
| Rate for Payer: Cash Price |
$281.50
|
| Rate for Payer: Cigna Commercial |
$467.29
|
| Rate for Payer: First Health Commercial |
$534.85
|
| Rate for Payer: Humana Commercial |
$478.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$461.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$415.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$495.44
|
| Rate for Payer: Ohio Health Group HMO |
$422.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.53
|
| Rate for Payer: PHCS Commercial |
$540.48
|
| Rate for Payer: United Healthcare All Payer |
$495.44
|
|
|
MODERATE SEDATION 1ST 15 MIN(P
|
Professional
|
Both
|
$180.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370P0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$10.11
|
| Rate for Payer: Anthem Medicaid |
$9.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$180.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$70.32
|
| Rate for Payer: Humana Medicaid |
$9.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$10.18
|
| Rate for Payer: Molina Healthcare Passport |
$9.98
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.00
|
| Rate for Payer: UHCCP Medicaid |
$10.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.08
|
|
|
MODERATE SEDATION 1ST 15 MIN(T
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370T0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$51.48 |
| Max. Negotiated Rate |
$380.16 |
| Rate for Payer: Aetna Commercial |
$304.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$308.88
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$328.68
|
| Rate for Payer: First Health Commercial |
$376.20
|
| Rate for Payer: Humana Commercial |
$336.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$324.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$292.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$348.48
|
| Rate for Payer: Ohio Health Group HMO |
$297.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.76
|
| Rate for Payer: PHCS Commercial |
$380.16
|
| Rate for Payer: United Healthcare All Payer |
$348.48
|
|
|
MODERATE SEDATION 1ST 15 MIN(T
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
370T0173
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$51.48 |
| Max. Negotiated Rate |
$380.16 |
| Rate for Payer: Aetna Commercial |
$304.92
|
| Rate for Payer: Anthem Medicaid |
$136.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$308.88
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cigna Commercial |
$328.68
|
| Rate for Payer: First Health Commercial |
$376.20
|
| Rate for Payer: Humana Commercial |
$336.60
|
| Rate for Payer: Humana KY Medicaid |
$136.18
|
| Rate for Payer: Kentucky WC Medicaid |
$137.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$324.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$292.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$348.48
|
| Rate for Payer: Ohio Health Group HMO |
$297.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$51.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.76
|
| Rate for Payer: PHCS Commercial |
$380.16
|
| Rate for Payer: United Healthcare All Payer |
$348.48
|
|
|
MOD HEAD 2MM HEMI HEAD 40MM
|
Facility
|
OP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem Medicaid |
$5,311.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Humana KY Medicaid |
$5,311.71
|
| Rate for Payer: Kentucky WC Medicaid |
$5,365.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,418.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
|
MOD HEAD 2MM HEMI HEAD 40MM
|
Facility
|
IP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
|
MOD HEAD 2MM HEMI HEAD 44MM
|
Facility
|
IP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
|
MOD HEAD 2MM HEMI HEAD 44MM
|
Facility
|
OP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem Medicaid |
$5,311.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Humana KY Medicaid |
$5,311.71
|
| Rate for Payer: Kentucky WC Medicaid |
$5,365.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,418.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
|
MOD HEAD 2MM HEMI HEAD 48MM
|
Facility
|
IP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
|
MOD HEAD 2MM HEMI HEAD 48MM
|
Facility
|
OP
|
$15,445.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,007.92 |
| Max. Negotiated Rate |
$14,827.68 |
| Rate for Payer: Aetna Commercial |
$11,893.04
|
| Rate for Payer: Anthem Medicaid |
$5,311.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,047.49
|
| Rate for Payer: Cash Price |
$7,722.75
|
| Rate for Payer: Cigna Commercial |
$12,819.76
|
| Rate for Payer: First Health Commercial |
$14,673.22
|
| Rate for Payer: Humana Commercial |
$13,128.68
|
| Rate for Payer: Humana KY Medicaid |
$5,311.71
|
| Rate for Payer: Kentucky WC Medicaid |
$5,365.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,665.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,398.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,633.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,418.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,592.04
|
| Rate for Payer: Ohio Health Group HMO |
$11,584.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,089.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,007.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,788.10
|
| Rate for Payer: PHCS Commercial |
$14,827.68
|
| Rate for Payer: United Healthcare All Payer |
$13,592.04
|
|
