|
ORTHOTIC FIT/TRAINING 15 MIN
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
43000031
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem Medicaid |
$28.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.52
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Humana KY Medicaid |
$28.89
|
| Rate for Payer: Kentucky WC Medicaid |
$29.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.04
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
ORTHOTIC FIT TRAINING 15MIN
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
42000037
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.52
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.04
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
ORTHOTIC FIT TRAINING 15MIN
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS 97760
|
| Hospital Charge Code |
42000037
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem Medicaid |
$28.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.52
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Humana KY Medicaid |
$28.89
|
| Rate for Payer: Kentucky WC Medicaid |
$29.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.04
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
IP
|
$2,509.50
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
636T0169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$326.24 |
| Max. Negotiated Rate |
$2,409.12 |
| Rate for Payer: Aetna Commercial |
$1,932.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.41
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cigna Commercial |
$2,082.88
|
| Rate for Payer: First Health Commercial |
$2,384.02
|
| Rate for Payer: Humana Commercial |
$2,133.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,057.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.94
|
| Rate for Payer: PHCS Commercial |
$2,409.12
|
| Rate for Payer: United Healthcare All Payer |
$2,208.36
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Professional
|
Both
|
$2,509.50
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
63600169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,509.50 |
| Rate for Payer: Aetna Commercial |
$203.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,509.50
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$186.48
|
| Rate for Payer: Multiplan PHCS |
$1,505.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,756.65
|
| Rate for Payer: UHCCP Medicaid |
$878.32
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
OP
|
$2,605.10
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
25004255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$2,500.90 |
| Rate for Payer: Aetna Commercial |
$2,005.93
|
| Rate for Payer: Anthem Medicaid |
$895.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$130.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,031.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$182.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.36
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cigna Commercial |
$2,162.23
|
| Rate for Payer: First Health Commercial |
$2,474.84
|
| Rate for Payer: Humana Commercial |
$2,214.34
|
| Rate for Payer: Humana KY Medicaid |
$895.89
|
| Rate for Payer: Humana Medicare Advantage |
$130.64
|
| Rate for Payer: Kentucky WC Medicaid |
$905.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,136.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,922.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$913.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,292.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,953.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$521.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.58
|
| Rate for Payer: PHCS Commercial |
$2,500.90
|
| Rate for Payer: United Healthcare All Payer |
$2,292.49
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
IP
|
$2,605.10
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
25004255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$338.66 |
| Max. Negotiated Rate |
$2,500.90 |
| Rate for Payer: Aetna Commercial |
$2,005.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,031.98
|
| Rate for Payer: Cash Price |
$1,302.55
|
| Rate for Payer: Cigna Commercial |
$2,162.23
|
| Rate for Payer: First Health Commercial |
$2,474.84
|
| Rate for Payer: Humana Commercial |
$2,214.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,136.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,922.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$781.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,292.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,953.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$521.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$807.58
|
| Rate for Payer: PHCS Commercial |
$2,500.90
|
| Rate for Payer: United Healthcare All Payer |
$2,292.49
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
OP
|
$2,509.50
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
63600169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$2,409.12 |
| Rate for Payer: Aetna Commercial |
$1,932.32
|
| Rate for Payer: Anthem Medicaid |
$863.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$130.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$182.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.36
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cigna Commercial |
$2,082.88
|
| Rate for Payer: First Health Commercial |
$2,384.02
|
| Rate for Payer: Humana Commercial |
$2,133.08
|
| Rate for Payer: Humana KY Medicaid |
$863.02
|
| Rate for Payer: Humana Medicare Advantage |
$130.64
|
| Rate for Payer: Kentucky WC Medicaid |
$871.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,057.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$880.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.94
|
| Rate for Payer: PHCS Commercial |
$2,409.12
|
| Rate for Payer: United Healthcare All Payer |
$2,208.36
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
IP
|
$2,509.50
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
63600169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$326.24 |
| Max. Negotiated Rate |
$2,409.12 |
| Rate for Payer: Aetna Commercial |
$1,932.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.41
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cigna Commercial |
$2,082.88
|
| Rate for Payer: First Health Commercial |
$2,384.02
|
| Rate for Payer: Humana Commercial |
$2,133.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,057.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.94
|
| Rate for Payer: PHCS Commercial |
$2,409.12
|
| Rate for Payer: United Healthcare All Payer |
$2,208.36
|
|
|
ORTHOVISC 30MG/2ML SYRINGE
|
Facility
|
OP
|
$2,509.50
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
636T0169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.64 |
| Max. Negotiated Rate |
$2,409.12 |
| Rate for Payer: Aetna Commercial |
$1,932.32
|
| Rate for Payer: Anthem Medicaid |
$863.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$130.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$182.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.36
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cash Price |
$1,254.75
|
| Rate for Payer: Cigna Commercial |
$2,082.88
|
| Rate for Payer: First Health Commercial |
$2,384.02
|
| Rate for Payer: Humana Commercial |
$2,133.08
|
| Rate for Payer: Humana KY Medicaid |
$863.02
|
| Rate for Payer: Humana Medicare Advantage |
$130.64
|
| Rate for Payer: Kentucky WC Medicaid |
$871.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,057.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$880.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.94
|
| Rate for Payer: PHCS Commercial |
$2,409.12
|
| Rate for Payer: United Healthcare All Payer |
$2,208.36
|
|
|
ORUDIS 50MG CAPSULE
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 378407001
|
| Hospital Charge Code |
25001142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
ORUDIS 50MG CAPSULE
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 378407001
|
| Hospital Charge Code |
25001142
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
OS 11-DEOXYCORTISOL
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 82634
|
| Hospital Charge Code |
30001947
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem Medicaid |
$29.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$29.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$40.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.28
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Humana KY Medicaid |
$29.28
|
| Rate for Payer: Humana Medicare Advantage |
$29.28
|
| Rate for Payer: Kentucky WC Medicaid |
$29.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
OS 11-DEOXYCORTISOL
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 82634
|
| Hospital Charge Code |
30001947
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
OS 17 HYDROXYPREGNENOLONE S
|
Facility
|
OP
|
$247.00
|
|
|
Service Code
|
HCPCS 84143
|
| Hospital Charge Code |
30000483
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$237.12 |
| Rate for Payer: Aetna Commercial |
$190.19
|
| Rate for Payer: Anthem Medicaid |
$22.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$198.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.81
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$205.01
|
| Rate for Payer: First Health Commercial |
$234.65
|
| Rate for Payer: Humana Commercial |
$209.95
|
| Rate for Payer: Humana KY Medicaid |
$22.81
|
| Rate for Payer: Humana Medicare Advantage |
$22.81
|
| Rate for Payer: Kentucky WC Medicaid |
$23.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.36
|
| Rate for Payer: Ohio Health Group HMO |
$185.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.57
|
| Rate for Payer: PHCS Commercial |
$237.12
|
| Rate for Payer: United Healthcare All Payer |
$217.36
|
|
|
OS 17 HYDROXYPREGNENOLONE S
|
Facility
|
IP
|
$247.00
|
|
|
Service Code
|
HCPCS 84143
|
| Hospital Charge Code |
30000483
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.11 |
| Max. Negotiated Rate |
$237.12 |
| Rate for Payer: Aetna Commercial |
$190.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$198.34
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$205.01
|
| Rate for Payer: First Health Commercial |
$234.65
|
| Rate for Payer: Humana Commercial |
$209.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.36
|
| Rate for Payer: Ohio Health Group HMO |
$185.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$76.57
|
| Rate for Payer: PHCS Commercial |
$237.12
|
| Rate for Payer: United Healthcare All Payer |
$217.36
|
|
|
OS 17 HYDROXYPROGESTERONE S
|
Professional
|
Both
|
$262.00
|
|
|
Service Code
|
HCPCS 83498
|
| Hospital Charge Code |
30000372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$262.00 |
| Rate for Payer: Aetna Commercial |
$37.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$262.00
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cigna Commercial |
$23.99
|
| Rate for Payer: Healthspan PPO |
$28.46
|
| Rate for Payer: Multiplan PHCS |
$157.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.40
|
| Rate for Payer: UHCCP Medicaid |
$91.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$16.30
|
|
|
OS 17 HYDROXYPROGESTERONE S
|
Facility
|
OP
|
$262.00
|
|
|
Service Code
|
HCPCS 83498
|
| Hospital Charge Code |
30000372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$251.52 |
| Rate for Payer: Aetna Commercial |
$201.74
|
| Rate for Payer: Anthem Medicaid |
$27.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$27.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$38.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.17
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cigna Commercial |
$217.46
|
| Rate for Payer: First Health Commercial |
$248.90
|
| Rate for Payer: Humana Commercial |
$222.70
|
| Rate for Payer: Humana KY Medicaid |
$27.17
|
| Rate for Payer: Humana Medicare Advantage |
$27.17
|
| Rate for Payer: Kentucky WC Medicaid |
$27.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$193.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$230.56
|
| Rate for Payer: Ohio Health Group HMO |
$196.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.22
|
| Rate for Payer: PHCS Commercial |
$251.52
|
| Rate for Payer: United Healthcare All Payer |
$230.56
|
|
|
OS 17 HYDROXYPROGESTERONE S
|
Facility
|
IP
|
$262.00
|
|
|
Service Code
|
HCPCS 83498
|
| Hospital Charge Code |
30000372
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.06 |
| Max. Negotiated Rate |
$251.52 |
| Rate for Payer: Aetna Commercial |
$201.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.39
|
| Rate for Payer: Cash Price |
$131.00
|
| Rate for Payer: Cigna Commercial |
$217.46
|
| Rate for Payer: First Health Commercial |
$248.90
|
| Rate for Payer: Humana Commercial |
$222.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$193.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$230.56
|
| Rate for Payer: Ohio Health Group HMO |
$196.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.22
|
| Rate for Payer: PHCS Commercial |
$251.52
|
| Rate for Payer: United Healthcare All Payer |
$230.56
|
|
|
OS 2,3-DINOR 11B-PROSTA F2A, U
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 84150
|
| Hospital Charge Code |
30001868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem Medicaid |
$41.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$58.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.77
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Humana KY Medicaid |
$41.77
|
| Rate for Payer: Humana Medicare Advantage |
$41.77
|
| Rate for Payer: Kentucky WC Medicaid |
$42.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.11
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
OS 2,3-DINOR 11B-PROSTA F2A, U
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 84150
|
| Hospital Charge Code |
30001868
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$77.76 |
| Rate for Payer: Aetna Commercial |
$62.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65.04
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$67.23
|
| Rate for Payer: First Health Commercial |
$76.95
|
| Rate for Payer: Humana Commercial |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.28
|
| Rate for Payer: Ohio Health Group HMO |
$60.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.11
|
| Rate for Payer: PHCS Commercial |
$77.76
|
| Rate for Payer: United Healthcare All Payer |
$71.28
|
|
|
OS 6 ACETYLMORPHINE CONFIRM UR
|
Facility
|
OP
|
$324.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000135
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$311.04 |
| Rate for Payer: Aetna Commercial |
$249.48
|
| Rate for Payer: Anthem Medicaid |
$114.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$260.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.43
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$268.92
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: Humana Commercial |
$275.40
|
| Rate for Payer: Humana KY Medicaid |
$114.43
|
| Rate for Payer: Humana Medicare Advantage |
$114.43
|
| Rate for Payer: Kentucky WC Medicaid |
$115.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.12
|
| Rate for Payer: Ohio Health Group HMO |
$243.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.44
|
| Rate for Payer: PHCS Commercial |
$311.04
|
| Rate for Payer: United Healthcare All Payer |
$285.12
|
|
|
OS 6 ACETYLMORPHINE CONFIRM UR
|
Facility
|
IP
|
$324.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000135
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$311.04 |
| Rate for Payer: Aetna Commercial |
$249.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$260.17
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$268.92
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: Humana Commercial |
$275.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.12
|
| Rate for Payer: Ohio Health Group HMO |
$243.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.44
|
| Rate for Payer: PHCS Commercial |
$311.04
|
| Rate for Payer: United Healthcare All Payer |
$285.12
|
|
|
OS A1AT/Fatty Acid Profile
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
30000290
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.66 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.15
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.42
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
|
OS A1AT/Fatty Acid Profile
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 82542
|
| Hospital Charge Code |
30000290
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.66 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem Medicaid |
$24.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$24.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$33.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.09
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Humana KY Medicaid |
$24.09
|
| Rate for Payer: Humana Medicare Advantage |
$24.09
|
| Rate for Payer: Kentucky WC Medicaid |
$24.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.42
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
