|
OXcarbazepine XR 600 MG Tablet
|
Facility
|
OP
|
$39.97
|
|
|
Service Code
|
NDC 17772012301
|
| Hospital Charge Code |
25004005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$38.37 |
| Rate for Payer: Aetna Commercial |
$30.78
|
| Rate for Payer: Anthem Medicaid |
$13.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.18
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cigna Commercial |
$33.18
|
| Rate for Payer: First Health Commercial |
$37.97
|
| Rate for Payer: Humana Commercial |
$33.97
|
| Rate for Payer: Humana KY Medicaid |
$13.75
|
| Rate for Payer: Kentucky WC Medicaid |
$13.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.17
|
| Rate for Payer: Ohio Health Group HMO |
$29.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.39
|
| Rate for Payer: PHCS Commercial |
$38.37
|
| Rate for Payer: United Healthcare All Payer |
$35.17
|
|
|
OXcarbazepine XR 600 MG Tablet
|
Facility
|
IP
|
$39.97
|
|
|
Service Code
|
NDC 17772012301
|
| Hospital Charge Code |
25004005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$38.37 |
| Rate for Payer: Aetna Commercial |
$30.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.18
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cigna Commercial |
$33.18
|
| Rate for Payer: First Health Commercial |
$37.97
|
| Rate for Payer: Humana Commercial |
$33.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.17
|
| Rate for Payer: Ohio Health Group HMO |
$29.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.39
|
| Rate for Payer: PHCS Commercial |
$38.37
|
| Rate for Payer: United Healthcare All Payer |
$35.17
|
|
|
OXEPA
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 70074054387
|
| Hospital Charge Code |
27000097
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
OXEPA
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
NDC 70074054387
|
| Hospital Charge Code |
27000097
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$71.04 |
| Rate for Payer: Aetna Commercial |
$56.98
|
| Rate for Payer: Anthem Medicaid |
$25.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.72
|
| Rate for Payer: Cash Price |
$37.00
|
| Rate for Payer: Cigna Commercial |
$61.42
|
| Rate for Payer: First Health Commercial |
$70.30
|
| Rate for Payer: Humana Commercial |
$62.90
|
| Rate for Payer: Humana KY Medicaid |
$25.45
|
| Rate for Payer: Kentucky WC Medicaid |
$25.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.12
|
| Rate for Payer: Ohio Health Group HMO |
$55.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.94
|
| Rate for Payer: PHCS Commercial |
$71.04
|
| Rate for Payer: United Healthcare All Payer |
$65.12
|
|
|
OXEPA RTH LIQ 1000ML
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
NDC 70074062717
|
| Hospital Charge Code |
25001147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem Medicaid |
$36.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$82.68
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Humana KY Medicaid |
$36.45
|
| Rate for Payer: Kentucky WC Medicaid |
$36.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.86
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
OXEPA RTH LIQ 1000ML
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
NDC 70074062717
|
| Hospital Charge Code |
25001147
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$101.76 |
| Rate for Payer: Aetna Commercial |
$81.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$82.68
|
| Rate for Payer: Cash Price |
$53.00
|
| Rate for Payer: Cigna Commercial |
$87.98
|
| Rate for Payer: First Health Commercial |
$100.70
|
| Rate for Payer: Humana Commercial |
$90.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$86.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$93.28
|
| Rate for Payer: Ohio Health Group HMO |
$79.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.86
|
| Rate for Payer: PHCS Commercial |
$101.76
|
| Rate for Payer: United Healthcare All Payer |
$93.28
|
|
|
OXI FM HEAD 14/16 TPR 28 +0
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 28 +0
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 28 +4
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 28 +4
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 28 +8
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 28 +8
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +0
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +0
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +4
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +4
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +8
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 32 +8
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +0
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +0
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +4
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +4
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +8
|
Facility
|
OP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem Medicaid |
$4,314.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Humana KY Medicaid |
$4,314.38
|
| Rate for Payer: Kentucky WC Medicaid |
$4,358.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,400.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXI FM HEAD 14/16 TPR 36 +8
|
Facility
|
IP
|
$12,545.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.91 |
| Max. Negotiated Rate |
$12,043.63 |
| Rate for Payer: Aetna Commercial |
$9,660.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,785.45
|
| Rate for Payer: Cash Price |
$6,272.73
|
| Rate for Payer: Cigna Commercial |
$10,412.72
|
| Rate for Payer: First Health Commercial |
$11,918.18
|
| Rate for Payer: Humana Commercial |
$10,663.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,287.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,258.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,763.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,409.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,509.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,889.09
|
| Rate for Payer: PHCS Commercial |
$12,043.63
|
| Rate for Payer: United Healthcare All Payer |
$11,040.00
|
|
|
OXIMETRY MULT DETERMINATION
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$301.00 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Anthem Medicaid |
$18.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$301.00
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$7.82
|
| Rate for Payer: Healthspan PPO |
$7.45
|
| Rate for Payer: Humana Medicaid |
$18.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare Passport |
$18.62
|
| Rate for Payer: Multiplan PHCS |
$180.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.70
|
| Rate for Payer: UHCCP Medicaid |
$105.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.81
|
|
