|
ORAJEL 20% GEL (7GM)
|
Facility
|
IP
|
$5.47
|
|
|
Service Code
|
NDC 10310028340
|
| Hospital Charge Code |
25004371
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$5.25 |
| Rate for Payer: Aetna Commercial |
$4.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.27
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cigna Commercial |
$4.54
|
| Rate for Payer: First Health Commercial |
$5.20
|
| Rate for Payer: Humana Commercial |
$4.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.81
|
| Rate for Payer: Ohio Health Group HMO |
$4.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.77
|
| Rate for Payer: PHCS Commercial |
$5.25
|
| Rate for Payer: United Healthcare All Payer |
$4.81
|
|
|
ORAP 1MG TABLET
|
Facility
|
OP
|
$9.36
|
|
|
Service Code
|
NDC 49884034701
|
| Hospital Charge Code |
25001138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem Medicaid |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.77
|
| Rate for Payer: First Health Commercial |
$8.89
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Humana KY Medicaid |
$3.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.46
|
| Rate for Payer: PHCS Commercial |
$8.99
|
| Rate for Payer: United Healthcare All Payer |
$8.24
|
|
|
ORAP 1MG TABLET
|
Facility
|
IP
|
$9.36
|
|
|
Service Code
|
NDC 49884034701
|
| Hospital Charge Code |
25001138
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.77
|
| Rate for Payer: First Health Commercial |
$8.89
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.24
|
| Rate for Payer: Ohio Health Group HMO |
$7.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.46
|
| Rate for Payer: PHCS Commercial |
$8.99
|
| Rate for Payer: United Healthcare All Payer |
$8.24
|
|
|
ORAP 2MG TABLET
|
Facility
|
OP
|
$9.81
|
|
|
Service Code
|
NDC 49884034801
|
| Hospital Charge Code |
25001139
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$9.42 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Anthem Medicaid |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.65
|
| Rate for Payer: Cash Price |
$4.90
|
| Rate for Payer: Cigna Commercial |
$8.14
|
| Rate for Payer: First Health Commercial |
$9.32
|
| Rate for Payer: Humana Commercial |
$8.34
|
| Rate for Payer: Humana KY Medicaid |
$3.37
|
| Rate for Payer: Kentucky WC Medicaid |
$3.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.63
|
| Rate for Payer: Ohio Health Group HMO |
$7.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.77
|
| Rate for Payer: PHCS Commercial |
$9.42
|
| Rate for Payer: United Healthcare All Payer |
$8.63
|
|
|
ORAP 2MG TABLET
|
Facility
|
IP
|
$9.81
|
|
|
Service Code
|
NDC 49884034801
|
| Hospital Charge Code |
25001139
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$9.42 |
| Rate for Payer: Aetna Commercial |
$7.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.65
|
| Rate for Payer: Cash Price |
$4.90
|
| Rate for Payer: Cigna Commercial |
$8.14
|
| Rate for Payer: First Health Commercial |
$9.32
|
| Rate for Payer: Humana Commercial |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.63
|
| Rate for Payer: Ohio Health Group HMO |
$7.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.77
|
| Rate for Payer: PHCS Commercial |
$9.42
|
| Rate for Payer: United Healthcare All Payer |
$8.63
|
|
|
ORAPRED(PRED SOD)5MG (15MG/5ML
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
HCPCS J7510
|
| Hospital Charge Code |
25002497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
ORAPRED(PRED SOD)5MG (15MG/5ML
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
HCPCS J7510
|
| Hospital Charge Code |
25002497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
ORBACTIV 400MG VIAL
|
Facility
|
OP
|
$6,142.15
|
|
|
Service Code
|
HCPCS J2407
|
| Hospital Charge Code |
25002287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.52 |
| Max. Negotiated Rate |
$5,896.46 |
| Rate for Payer: Aetna Commercial |
$4,729.46
|
| Rate for Payer: Anthem Medicaid |
$2,112.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,790.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.50
|
| Rate for Payer: Cash Price |
$3,071.07
|
| Rate for Payer: Cash Price |
$3,071.07
|
| Rate for Payer: Cigna Commercial |
$5,097.98
|
| Rate for Payer: First Health Commercial |
$5,835.04
|
| Rate for Payer: Humana Commercial |
$5,220.83
|
| Rate for Payer: Humana KY Medicaid |
$2,112.29
|
| Rate for Payer: Humana Medicare Advantage |
$28.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,133.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,036.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,532.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,154.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,405.09
|
| Rate for Payer: Ohio Health Group HMO |
$4,606.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,913.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,343.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,238.08
|
| Rate for Payer: PHCS Commercial |
$5,896.46
|
| Rate for Payer: United Healthcare All Payer |
$5,405.09
|
|
|
ORBACTIV 400MG VIAL
|
Facility
|
IP
|
$6,142.15
|
|
|
Service Code
|
HCPCS J2407
|
| Hospital Charge Code |
25002287
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,842.64 |
| Max. Negotiated Rate |
$5,896.46 |
| Rate for Payer: Aetna Commercial |
$4,729.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,790.88
|
| Rate for Payer: Cash Price |
$3,071.07
|
| Rate for Payer: Cigna Commercial |
$5,097.98
|
| Rate for Payer: First Health Commercial |
$5,835.04
|
| Rate for Payer: Humana Commercial |
$5,220.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,036.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,532.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,842.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,405.09
|
| Rate for Payer: Ohio Health Group HMO |
$4,606.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,913.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,343.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,238.08
|
| Rate for Payer: PHCS Commercial |
$5,896.46
|
| Rate for Payer: United Healthcare All Payer |
$5,405.09
|
|
|
ORBICULARIS OCULI (BLINK) REFL
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
51000040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: Anthem Medicaid |
$145.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$351.09
|
| Rate for Payer: First Health Commercial |
$401.85
|
| Rate for Payer: Humana Commercial |
$359.55
|
| Rate for Payer: Humana KY Medicaid |
$145.47
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$146.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$148.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$372.24
|
| Rate for Payer: Ohio Health Group HMO |
$317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$338.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$368.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.87
|
| Rate for Payer: PHCS Commercial |
$406.08
|
| Rate for Payer: United Healthcare All Payer |
$372.24
|
|
|
ORBICULARIS OCULI (BLINK) REFL
|
Professional
|
Both
|
$423.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
51000040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$98.45
|
| Rate for Payer: Ambetter Exchange |
$72.58
|
| Rate for Payer: Anthem Medicaid |
$53.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.10
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$96.78
|
| Rate for Payer: Healthspan PPO |
$86.72
|
| Rate for Payer: Humana Medicaid |
$53.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.34
|
| Rate for Payer: Molina Healthcare Passport |
$53.27
|
| Rate for Payer: Multiplan PHCS |
$253.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.35
|
| Rate for Payer: UHCCP Medicaid |
$148.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.58
|
|
|
ORBICULARIS OCULI (BLINK) REFL
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
51000040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$126.90 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.94
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$351.09
|
| Rate for Payer: First Health Commercial |
$401.85
|
| Rate for Payer: Humana Commercial |
$359.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$372.24
|
| Rate for Payer: Ohio Health Group HMO |
$317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$338.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$368.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.87
|
| Rate for Payer: PHCS Commercial |
$406.08
|
| Rate for Payer: United Healthcare All Payer |
$372.24
|
|
|
ORBICULARIS OCULI BLINK REFL(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
510P0040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$98.45 |
| Rate for Payer: Aetna Commercial |
$98.45
|
| Rate for Payer: Ambetter Exchange |
$72.58
|
| Rate for Payer: Anthem Medicaid |
$53.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.10
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$96.78
|
| Rate for Payer: Healthspan PPO |
$86.72
|
| Rate for Payer: Humana Medicaid |
$53.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.34
|
| Rate for Payer: Molina Healthcare Passport |
$53.27
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.35
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.58
|
|
|
ORBICULARIS OCULI BLINK REF(T
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
510T0040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$310.08 |
| Rate for Payer: Aetna Commercial |
$248.71
|
| Rate for Payer: Anthem Medicaid |
$111.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cigna Commercial |
$268.09
|
| Rate for Payer: First Health Commercial |
$306.85
|
| Rate for Payer: Humana Commercial |
$274.55
|
| Rate for Payer: Humana KY Medicaid |
$111.08
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$112.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.24
|
| Rate for Payer: Ohio Health Group HMO |
$242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.87
|
| Rate for Payer: PHCS Commercial |
$310.08
|
| Rate for Payer: United Healthcare All Payer |
$284.24
|
|
|
ORBICULARIS OCULI BLINK REF(T
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
HCPCS 95933
|
| Hospital Charge Code |
510T0040
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$310.08 |
| Rate for Payer: Aetna Commercial |
$248.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.94
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cigna Commercial |
$268.09
|
| Rate for Payer: First Health Commercial |
$306.85
|
| Rate for Payer: Humana Commercial |
$274.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.24
|
| Rate for Payer: Ohio Health Group HMO |
$242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.87
|
| Rate for Payer: PHCS Commercial |
$310.08
|
| Rate for Payer: United Healthcare All Payer |
$284.24
|
|
|
ORBITS COMPLETE 4 VIEWS
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
32000014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$180.30 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
ORBITS COMPLETE 4 VIEWS
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
32000014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem Medicaid |
$206.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Humana KY Medicaid |
$206.68
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$208.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
ORBITS COMPLETE 4 VIEWS
|
Professional
|
Both
|
$601.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
32000014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$17.67 |
| Max. Negotiated Rate |
$360.60 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Ambetter Exchange |
$43.02
|
| Rate for Payer: Anthem Medicaid |
$33.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$43.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$43.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.62
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$65.58
|
| Rate for Payer: Healthspan PPO |
$62.77
|
| Rate for Payer: Humana Medicaid |
$33.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$43.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.19
|
| Rate for Payer: Molina Healthcare Passport |
$33.52
|
| Rate for Payer: Multiplan PHCS |
$360.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.93
|
| Rate for Payer: UHCCP Medicaid |
$210.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$43.02
|
|
|
ORBITS COMPLETE 4 VIEWS(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
320P0014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$17.67 |
| Max. Negotiated Rate |
$66.99 |
| Rate for Payer: Aetna Commercial |
$66.99
|
| Rate for Payer: Ambetter Exchange |
$43.02
|
| Rate for Payer: Anthem Medicaid |
$33.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$43.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$43.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.62
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$65.58
|
| Rate for Payer: Healthspan PPO |
$62.77
|
| Rate for Payer: Humana Medicaid |
$33.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$17.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$43.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.19
|
| Rate for Payer: Molina Healthcare Passport |
$33.52
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.93
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$43.02
|
|
|
ORBITS COMPLETE 4 VIEWS(T
|
Facility
|
IP
|
$526.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
320T0014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$157.80 |
| Max. Negotiated Rate |
$504.96 |
| Rate for Payer: Aetna Commercial |
$405.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$410.28
|
| Rate for Payer: Cash Price |
$263.00
|
| Rate for Payer: Cigna Commercial |
$436.58
|
| Rate for Payer: First Health Commercial |
$499.70
|
| Rate for Payer: Humana Commercial |
$447.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$431.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$157.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$462.88
|
| Rate for Payer: Ohio Health Group HMO |
$394.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$457.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.94
|
| Rate for Payer: PHCS Commercial |
$504.96
|
| Rate for Payer: United Healthcare All Payer |
$462.88
|
|
|
ORBITS COMPLETE 4 VIEWS(T
|
Facility
|
OP
|
$526.00
|
|
|
Service Code
|
HCPCS 70200
|
| Hospital Charge Code |
320T0014
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$504.96 |
| Rate for Payer: Aetna Commercial |
$405.02
|
| Rate for Payer: Anthem Medicaid |
$180.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$410.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$263.00
|
| Rate for Payer: Cash Price |
$263.00
|
| Rate for Payer: Cigna Commercial |
$436.58
|
| Rate for Payer: First Health Commercial |
$499.70
|
| Rate for Payer: Humana Commercial |
$447.10
|
| Rate for Payer: Humana KY Medicaid |
$180.89
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$182.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$431.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$388.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$184.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$462.88
|
| Rate for Payer: Ohio Health Group HMO |
$394.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$457.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.94
|
| Rate for Payer: PHCS Commercial |
$504.96
|
| Rate for Payer: United Healthcare All Payer |
$462.88
|
|
|
ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH
|
Facility
|
OP
|
$4,565.09
|
|
|
Service Code
|
CPT 54530
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,260.78 |
| Max. Negotiated Rate |
$4,565.09 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,260.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,565.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,402.05
|
| Rate for Payer: Humana Medicare Advantage |
$3,260.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.94
|
|
|
ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH
|
Facility
|
OP
|
$4,461.49
|
|
|
Service Code
|
CPT 54520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,186.78 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
|
|
ORCHIOPEXY INGUN/SCROT APPR
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
HCPCS 54640
|
| Hospital Charge Code |
36001274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.00 |
| 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 |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
ORCHIOPEXY INGUN/SCROT APPR
|
Professional
|
Both
|
$640.00
|
|
|
Service Code
|
HCPCS 54640
|
| Hospital Charge Code |
36001274
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$224.00 |
| Max. Negotiated Rate |
$755.73 |
| Rate for Payer: Aetna Commercial |
$755.73
|
| Rate for Payer: Ambetter Exchange |
$411.05
|
| Rate for Payer: Anthem Medicaid |
$349.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$411.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$411.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$493.26
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$667.69
|
| Rate for Payer: Healthspan PPO |
$731.74
|
| Rate for Payer: Humana Medicaid |
$349.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$646.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$411.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$411.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$356.45
|
| Rate for Payer: Molina Healthcare Passport |
$349.46
|
| Rate for Payer: Multiplan PHCS |
$384.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$534.37
|
| Rate for Payer: UHCCP Medicaid |
$224.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$352.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$411.05
|
|
