|
OXcarbazepine XR 300 MG Tablet
|
Facility
|
IP
|
$30.30
|
|
|
Service Code
|
NDC 17772012201
|
| Hospital Charge Code |
25004004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$29.09 |
| Rate for Payer: Aetna Commercial |
$23.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.63
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cigna Commercial |
$25.15
|
| Rate for Payer: First Health Commercial |
$28.79
|
| Rate for Payer: Humana Commercial |
$25.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.66
|
| Rate for Payer: Ohio Health Group HMO |
$22.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.91
|
| Rate for Payer: PHCS Commercial |
$29.09
|
| Rate for Payer: United Healthcare All Payer |
$26.66
|
|
|
OXcarbazepine XR 600 MG Tablet
|
Facility
|
IP
|
$41.34
|
|
|
Service Code
|
NDC 17772012301
|
| Hospital Charge Code |
25004005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$39.69 |
| Rate for Payer: Aetna Commercial |
$31.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.25
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna Commercial |
$34.31
|
| Rate for Payer: First Health Commercial |
$39.27
|
| Rate for Payer: Humana Commercial |
$35.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.38
|
| Rate for Payer: Ohio Health Group HMO |
$31.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$39.69
|
| Rate for Payer: United Healthcare All Payer |
$36.38
|
|
|
OXcarbazepine XR 600 MG Tablet
|
Facility
|
OP
|
$41.34
|
|
|
Service Code
|
NDC 17772012301
|
| Hospital Charge Code |
25004005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$39.69 |
| Rate for Payer: Aetna Commercial |
$31.83
|
| Rate for Payer: Anthem Medicaid |
$14.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32.25
|
| Rate for Payer: Cash Price |
$20.67
|
| Rate for Payer: Cigna Commercial |
$34.31
|
| Rate for Payer: First Health Commercial |
$39.27
|
| Rate for Payer: Humana Commercial |
$35.14
|
| Rate for Payer: Humana KY Medicaid |
$14.22
|
| Rate for Payer: Kentucky WC Medicaid |
$14.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$36.38
|
| Rate for Payer: Ohio Health Group HMO |
$31.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.52
|
| Rate for Payer: PHCS Commercial |
$39.69
|
| Rate for Payer: United Healthcare All Payer |
$36.38
|
|
|
OXI FM HEAD 14/16 TPR 28 +0
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 28 +0
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 28 +4
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 28 +4
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 28 +8
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 28 +8
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +0
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +0
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +4
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +4
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +8
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 32 +8
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +0
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +0
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +4
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +4
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +8
|
Facility
|
OP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem Medicaid |
$4,400.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Humana KY Medicaid |
$4,400.58
|
| Rate for Payer: Kentucky WC Medicaid |
$4,445.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,488.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXI FM HEAD 14/16 TPR 36 +8
|
Facility
|
IP
|
$12,796.11
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,838.83 |
| Max. Negotiated Rate |
$12,284.27 |
| Rate for Payer: Aetna Commercial |
$9,853.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,980.97
|
| Rate for Payer: Cash Price |
$6,398.06
|
| Rate for Payer: Cigna Commercial |
$10,620.77
|
| Rate for Payer: First Health Commercial |
$12,156.30
|
| Rate for Payer: Humana Commercial |
$10,876.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,492.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,838.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,260.58
|
| Rate for Payer: Ohio Health Group HMO |
$9,597.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,236.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,132.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,829.32
|
| Rate for Payer: PHCS Commercial |
$12,284.27
|
| Rate for Payer: United Healthcare All Payer |
$11,260.58
|
|
|
OXIMETRY MULT DETERMINATION
|
Facility
|
IP
|
$308.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$295.68 |
| Rate for Payer: Aetna Commercial |
$237.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$240.24
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cigna Commercial |
$255.64
|
| Rate for Payer: First Health Commercial |
$292.60
|
| Rate for Payer: Humana Commercial |
$261.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$252.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$227.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.04
|
| Rate for Payer: Ohio Health Group HMO |
$231.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$246.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$267.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$212.52
|
| Rate for Payer: PHCS Commercial |
$295.68
|
| Rate for Payer: United Healthcare All Payer |
$271.04
|
|
|
OXIMETRY MULT DETERMINATION
|
Professional
|
Both
|
$308.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$184.80 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Ambetter Exchange |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$18.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$3.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.30
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cash Price |
$154.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare Passport |
$18.62
|
| Rate for Payer: Multiplan PHCS |
$184.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4.65
|
| Rate for Payer: UHCCP Medicaid |
$107.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$3.58
|
|
|
OXIMETRY MULT DETERMINATION
|
Facility
|
OP
|
$308.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$295.68 |
| Rate for Payer: Aetna Commercial |
$237.16
|
| Rate for Payer: Anthem Medicaid |
$105.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$240.24
|
| Rate for Payer: Cash Price |
$154.00
|
| Rate for Payer: Cigna Commercial |
$255.64
|
| Rate for Payer: First Health Commercial |
$292.60
|
| Rate for Payer: Humana Commercial |
$261.80
|
| Rate for Payer: Humana KY Medicaid |
$105.92
|
| Rate for Payer: Kentucky WC Medicaid |
$107.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$252.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$227.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$108.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.04
|
| Rate for Payer: Ohio Health Group HMO |
$231.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$246.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$267.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$212.52
|
| Rate for Payer: PHCS Commercial |
$295.68
|
| Rate for Payer: United Healthcare All Payer |
$271.04
|
|
|
OXIMETRY MULT DETERMINATION(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460P0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Ambetter Exchange |
$3.58
|
| Rate for Payer: Anthem Medicaid |
$18.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$3.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$3.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.30
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare Passport |
$18.62
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4.65
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$3.58
|
|
