|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
77000041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLIOVIRUS VACC INACTIVE (IPV)
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90713
|
| Hospital Charge Code |
770T0041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
POLYMYXIN B SULFAT 500000U/1EA
|
Facility
|
IP
|
$117.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.27
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
POLYMYXIN B SULFAT 500000U/1EA
|
Facility
|
OP
|
$117.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$112.32 |
| Rate for Payer: Aetna Commercial |
$90.09
|
| Rate for Payer: Anthem Medicaid |
$40.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.26
|
| Rate for Payer: Cash Price |
$58.50
|
| Rate for Payer: Cigna Commercial |
$97.11
|
| Rate for Payer: First Health Commercial |
$111.15
|
| Rate for Payer: Humana Commercial |
$99.45
|
| Rate for Payer: Humana KY Medicaid |
$40.24
|
| Rate for Payer: Kentucky WC Medicaid |
$40.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.96
|
| Rate for Payer: Ohio Health Group HMO |
$87.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.27
|
| Rate for Payer: PHCS Commercial |
$112.32
|
| Rate for Payer: United Healthcare All Payer |
$102.96
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Facility
|
OP
|
$5,036.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$654.68 |
| Max. Negotiated Rate |
$4,834.56 |
| Rate for Payer: Aetna Commercial |
$3,877.72
|
| Rate for Payer: Anthem Medicaid |
$1,731.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$904.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,928.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,265.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,220.58
|
| Rate for Payer: Cash Price |
$2,518.00
|
| Rate for Payer: Cash Price |
$2,518.00
|
| Rate for Payer: Cigna Commercial |
$4,179.88
|
| Rate for Payer: First Health Commercial |
$4,784.20
|
| Rate for Payer: Humana Commercial |
$4,280.60
|
| Rate for Payer: Humana KY Medicaid |
$1,731.88
|
| Rate for Payer: Humana Medicare Advantage |
$904.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,749.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,129.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,716.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,766.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,431.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,777.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,007.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$654.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,561.16
|
| Rate for Payer: PHCS Commercial |
$4,834.56
|
| Rate for Payer: United Healthcare All Payer |
$4,431.68
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Facility
|
IP
|
$5,036.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$654.68 |
| Max. Negotiated Rate |
$4,834.56 |
| Rate for Payer: Aetna Commercial |
$3,877.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,928.08
|
| Rate for Payer: Cash Price |
$2,518.00
|
| Rate for Payer: Cigna Commercial |
$4,179.88
|
| Rate for Payer: First Health Commercial |
$4,784.20
|
| Rate for Payer: Humana Commercial |
$4,280.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,129.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,716.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,510.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,431.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,777.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,007.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$654.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,561.16
|
| Rate for Payer: PHCS Commercial |
$4,834.56
|
| Rate for Payer: United Healthcare All Payer |
$4,431.68
|
|
|
POLYSOMNOGRAPHY MON <6HR
|
Professional
|
Both
|
$5,036.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
74000003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$150.32 |
| Max. Negotiated Rate |
$5,036.00 |
| Rate for Payer: Aetna Commercial |
$1,164.16
|
| Rate for Payer: Anthem Medicaid |
$542.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,036.00
|
| Rate for Payer: Cash Price |
$2,518.00
|
| Rate for Payer: Cash Price |
$2,518.00
|
| Rate for Payer: Cigna Commercial |
$1,218.77
|
| Rate for Payer: Healthspan PPO |
$1,018.12
|
| Rate for Payer: Humana Medicaid |
$542.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$553.27
|
| Rate for Payer: Molina Healthcare Passport |
$542.42
|
| Rate for Payer: Multiplan PHCS |
$3,021.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,525.20
|
| Rate for Payer: UHCCP Medicaid |
$1,762.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$547.84
|
|
|
POLYSOMNOGRAPHY MON <6HR(P
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740P0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$1,218.77 |
| Rate for Payer: Aetna Commercial |
$1,164.16
|
| Rate for Payer: Anthem Medicaid |
$542.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$315.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$1,218.77
|
| Rate for Payer: Healthspan PPO |
$1,018.12
|
| Rate for Payer: Humana Medicaid |
$542.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$150.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$553.27
|
| Rate for Payer: Molina Healthcare Passport |
$542.42
|
| Rate for Payer: Multiplan PHCS |
$189.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$220.50
|
| Rate for Payer: UHCCP Medicaid |
$110.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$547.84
|
|
|
POLYSOMNOGRAPHY MON <6HR(T
|
Facility
|
IP
|
$4,721.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740T0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$613.73 |
| Max. Negotiated Rate |
$4,532.16 |
| Rate for Payer: Aetna Commercial |
$3,635.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,682.38
|
| Rate for Payer: Cash Price |
$2,360.50
|
| Rate for Payer: Cigna Commercial |
$3,918.43
|
| Rate for Payer: First Health Commercial |
$4,484.95
|
| Rate for Payer: Humana Commercial |
$4,012.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,871.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,484.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,154.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.51
|
| Rate for Payer: PHCS Commercial |
$4,532.16
|
| Rate for Payer: United Healthcare All Payer |
$4,154.48
|
|
|
POLYSOMNOGRAPHY MON <6HR(T
|
Facility
|
OP
|
$4,721.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
740T0003
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$613.73 |
| Max. Negotiated Rate |
$4,532.16 |
| Rate for Payer: Aetna Commercial |
$3,635.17
|
| Rate for Payer: Anthem Medicaid |
$1,623.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$904.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,682.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,265.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,220.58
|
| Rate for Payer: Cash Price |
$2,360.50
|
| Rate for Payer: Cash Price |
$2,360.50
|
| Rate for Payer: Cigna Commercial |
$3,918.43
|
| Rate for Payer: First Health Commercial |
$4,484.95
|
| Rate for Payer: Humana Commercial |
$4,012.85
|
| Rate for Payer: Humana KY Medicaid |
$1,623.55
|
| Rate for Payer: Humana Medicare Advantage |
$904.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,871.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,484.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,656.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,154.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.51
|
| Rate for Payer: PHCS Commercial |
$4,532.16
|
| Rate for Payer: United Healthcare All Payer |
$4,154.48
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Facility
|
IP
|
$5,846.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$759.98 |
| Max. Negotiated Rate |
$5,612.16 |
| Rate for Payer: Aetna Commercial |
$4,501.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,559.88
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cigna Commercial |
$4,852.18
|
| Rate for Payer: First Health Commercial |
$5,553.70
|
| Rate for Payer: Humana Commercial |
$4,969.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,793.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,314.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,753.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,144.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,812.26
|
| Rate for Payer: PHCS Commercial |
$5,612.16
|
| Rate for Payer: United Healthcare All Payer |
$5,144.48
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Professional
|
Both
|
$5,846.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$157.27 |
| Max. Negotiated Rate |
$5,846.00 |
| Rate for Payer: Aetna Commercial |
$1,281.26
|
| Rate for Payer: Anthem Medicaid |
$597.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,846.00
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cigna Commercial |
$1,335.20
|
| Rate for Payer: Healthspan PPO |
$1,120.53
|
| Rate for Payer: Humana Medicaid |
$597.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.79
|
| Rate for Payer: Molina Healthcare Passport |
$597.83
|
| Rate for Payer: Multiplan PHCS |
$3,507.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,092.20
|
| Rate for Payer: UHCCP Medicaid |
$2,046.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.81
|
|
|
POLYSOMNOMON W C/BPAP<6HR
|
Facility
|
OP
|
$5,846.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
74000004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$759.98 |
| Max. Negotiated Rate |
$5,612.16 |
| Rate for Payer: Aetna Commercial |
$4,501.42
|
| Rate for Payer: Anthem Medicaid |
$2,010.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$904.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,559.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,265.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,220.58
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cigna Commercial |
$4,852.18
|
| Rate for Payer: First Health Commercial |
$5,553.70
|
| Rate for Payer: Humana Commercial |
$4,969.10
|
| Rate for Payer: Humana KY Medicaid |
$2,010.44
|
| Rate for Payer: Humana Medicare Advantage |
$904.13
|
| Rate for Payer: Kentucky WC Medicaid |
$2,030.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,793.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,314.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,050.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,144.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,812.26
|
| Rate for Payer: PHCS Commercial |
$5,612.16
|
| Rate for Payer: United Healthcare All Payer |
$5,144.48
|
|
|
POLYSOMNOMON W C/BPAP<6HR(P
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740P0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$117.25 |
| Max. Negotiated Rate |
$1,335.20 |
| Rate for Payer: Aetna Commercial |
$1,281.26
|
| Rate for Payer: Anthem Medicaid |
$597.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$335.00
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$1,335.20
|
| Rate for Payer: Healthspan PPO |
$1,120.53
|
| Rate for Payer: Humana Medicaid |
$597.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.79
|
| Rate for Payer: Molina Healthcare Passport |
$597.83
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.50
|
| Rate for Payer: UHCCP Medicaid |
$117.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.81
|
|
|
POLYSOMNOMON W C/BPAP<6HR(T
|
Facility
|
OP
|
$5,511.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740T0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$716.43 |
| Max. Negotiated Rate |
$5,290.56 |
| Rate for Payer: Aetna Commercial |
$4,243.47
|
| Rate for Payer: Anthem Medicaid |
$1,895.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$904.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,298.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,265.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,220.58
|
| Rate for Payer: Cash Price |
$2,755.50
|
| Rate for Payer: Cash Price |
$2,755.50
|
| Rate for Payer: Cigna Commercial |
$4,574.13
|
| Rate for Payer: First Health Commercial |
$5,235.45
|
| Rate for Payer: Humana Commercial |
$4,684.35
|
| Rate for Payer: Humana KY Medicaid |
$1,895.23
|
| Rate for Payer: Humana Medicare Advantage |
$904.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,914.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,519.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,067.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,933.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,849.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,133.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,708.41
|
| Rate for Payer: PHCS Commercial |
$5,290.56
|
| Rate for Payer: United Healthcare All Payer |
$4,849.68
|
|
|
POLYSOMNOMON W C/BPAP<6HR(T
|
Facility
|
IP
|
$5,511.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740T0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$716.43 |
| Max. Negotiated Rate |
$5,290.56 |
| Rate for Payer: Aetna Commercial |
$4,243.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,298.58
|
| Rate for Payer: Cash Price |
$2,755.50
|
| Rate for Payer: Cigna Commercial |
$4,574.13
|
| Rate for Payer: First Health Commercial |
$5,235.45
|
| Rate for Payer: Humana Commercial |
$4,684.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,519.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,067.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,653.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,849.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,133.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,708.41
|
| Rate for Payer: PHCS Commercial |
$5,290.56
|
| Rate for Payer: United Healthcare All Payer |
$4,849.68
|
|
|
POLYSPORIN BACITR/POLYMYX 15GM
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
25003360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.28
|
| Rate for Payer: Anthem Medicaid |
$0.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.29
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna Commercial |
$0.31
|
| Rate for Payer: First Health Commercial |
$0.35
|
| Rate for Payer: Humana Commercial |
$0.31
|
| Rate for Payer: Humana KY Medicaid |
$0.13
|
| Rate for Payer: Kentucky WC Medicaid |
$0.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.33
|
| Rate for Payer: Ohio Health Group HMO |
$0.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.11
|
| Rate for Payer: PHCS Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Payer |
$0.33
|
|
|
POLYSPORIN BACITR/POLYMYX 15GM
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
25003360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.29
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna Commercial |
$0.31
|
| Rate for Payer: First Health Commercial |
$0.35
|
| Rate for Payer: Humana Commercial |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.33
|
| Rate for Payer: Ohio Health Group HMO |
$0.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.11
|
| Rate for Payer: PHCS Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Payer |
$0.33
|
|
|
POLYSPORIN EYE OINT
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
25001198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.54
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cigna Commercial |
$2.71
|
| Rate for Payer: First Health Commercial |
$3.10
|
| Rate for Payer: Humana Commercial |
$2.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.87
|
| Rate for Payer: Ohio Health Group HMO |
$2.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.01
|
| Rate for Payer: PHCS Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Payer |
$2.87
|
|
|
POLYSPORIN EYE OINT
|
Facility
|
OP
|
$3.26
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
25001198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Anthem Medicaid |
$1.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.54
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cigna Commercial |
$2.71
|
| Rate for Payer: First Health Commercial |
$3.10
|
| Rate for Payer: Humana Commercial |
$2.77
|
| Rate for Payer: Humana KY Medicaid |
$1.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.87
|
| Rate for Payer: Ohio Health Group HMO |
$2.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.01
|
| Rate for Payer: PHCS Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Payer |
$2.87
|
|
|
POLYSPORIN OINT.PACKET
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 12547023813
|
| Hospital Charge Code |
25003361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem Medicaid |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Humana KY Medicaid |
$0.08
|
| Rate for Payer: Kentucky WC Medicaid |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
POLYSPORIN OINT.PACKET
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 12547023813
|
| Hospital Charge Code |
25003361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
POLYTRIM (TRIMETH/POLYMYX 10ML
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
25001200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Anthem Medicaid |
$0.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: First Health Commercial |
$0.41
|
| Rate for Payer: Humana Commercial |
$0.37
|
| Rate for Payer: Humana KY Medicaid |
$0.15
|
| Rate for Payer: Kentucky WC Medicaid |
$0.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.38
|
| Rate for Payer: Ohio Health Group HMO |
$0.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.13
|
| Rate for Payer: PHCS Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Payer |
$0.38
|
|
|
POLYTRIM (TRIMETH/POLYMYX 10ML
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
25001200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: First Health Commercial |
$0.41
|
| Rate for Payer: Humana Commercial |
$0.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.38
|
| Rate for Payer: Ohio Health Group HMO |
$0.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.13
|
| Rate for Payer: PHCS Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Payer |
$0.38
|
|
|
PORT DRAW
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
HCPCS 36591
|
| Hospital Charge Code |
76101492
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$164.16 |
| Rate for Payer: Aetna Commercial |
$131.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$137.31
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$141.93
|
| Rate for Payer: First Health Commercial |
$162.45
|
| Rate for Payer: Humana Commercial |
$145.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$140.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$150.48
|
| Rate for Payer: Ohio Health Group HMO |
$128.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.01
|
| Rate for Payer: PHCS Commercial |
$164.16
|
| Rate for Payer: United Healthcare All Payer |
$150.48
|
|
